Richard N Bradley

Cardiac arrest survival as a function of ambulance deployment strategy in a large urban emergency medical services system

INTRODUCTION This study examines the effect of paramedic deployment strategy on witnessed ventricular fibrillation (VF) cardiac arrest outcomes. Our null hypothesis was that there is no difference in survival between an EMS system using targeted response (TR) and one using a uniform or all advanced life support (ALS) response (UR) model. We define targeted response as a system where paramedics are sent to critical incidents while ambulances staffed with basic EMTs are sent to less critical incidents. A secondary outcome measure was paramedic skill proficiency between the systems. METHODS We conducted a retrospective review of all 1997 VF arrests in a large urban EMS system. The majority of the city is a busy, urban area that uses TR. Outlying areas of the city are suburban and are served by a UR model. All areas have first responders equipped with automated external defibrillators. Outcomes are compared using Utstein criteria. RESULTS Patient populations were well matched. There were 181 patients in the TR group and 24 in the UR group. Units in the TR area were able to demonstrate shorter response and time to defibrillation intervals than in the UR area. Rates for return of spontaneous circulation (ROSC), admission to the ward/intensive care unit (ICU), survival to discharge and survival to 1 year were all better in the cohort of patients cared for in the TR area than those in the UR area. Rates for successful intubation and IV initiation were also better in the TR areas than in the UR areas. CONCLUSION This study shows improved outcomes for a subset of patients with cardiac arrest when they are cared for in an area that uses TR compared to an area that uses a UR EMS system.

Association of Bystander Cardiopulmonary Resuscitation With Overall and Neurologically Favorable Survival After Pediatric Out-of-Hospital Cardiac Arrest in the United States: A Report From the Cardiac Arrest Registry to Enhance Survival Surveillance Registry

Importance There are few data on the prevalence or outcome of bystander cardiopulmonary resuscitation (BCPR) in children 18 years and younger. Objective To characterize BCPR in pediatric out-of-hospital cardiac arrests (OHCAs). Design, Setting, and Participants This analysis of the Cardiac Arrest Registry to Enhance Survival database investigated nontraumatic OHCAs in children 18 years and younger from January 2013 through December 2015. Exposures Bystander CPR, which included conventional CPR and compression-only CPR. Main Outcomes and Measures Overall survival and neurologically favorable survival, defined as a Cerebral Performance Category score of 1 or 2, at the time of hospital discharge. Results Of the 3900 children younger than 18 years with OHCA, 2317 (59.4%) were infants, 2346 (60.2%) were female, and 3595 (92.2%) had nonshockable rhythms. Bystander CPR was performed on 1814 children (46.5%) and was more common for white children (687 of 1221 [56.3%]) compared with African American children (447 of 1134 [39.4%]) and Hispanic children (197 of 455 [43.3%]) (P < .001). Overall survival and neurologically favorable survival were 11.3% (440 of 3900) and 9.1% (354 of 3900), respectively. On multivariable analysis, BCPR was independently associated with improved overall survival (adjusted proportion, 13.2%; 95% CI, 11.81-14.58; adjusted odds ratio, 1.57; 95% CI, 1.25-1.96) and neurologically favorable survival (adjusted proportion, 10.3%; 95% CI, 9.10-11.54; adjusted odds ratio, 1.50; 95% CI, 1.21-1.98) compared with no BCPR (overall survival: adjusted proportion, 9.5%; 95% CI, 8.28-10.69; neurologically favorable survival: adjusted proportion, 7.59%; 95% CI, 6.50-8.68). For those with data on type of BCPR, 697 of 1411 (49.4%) received conventional CPR and 714 of 1411 (50.6%) received compression-only CPR. On multivariable analysis, only conventional CPR (adjusted proportion, 12.89%; 95% CI, 10.69-15.09; adjusted odds ratio, 2.06; 95% CI, 1.51-2.79) was associated with improved neurologically favorable survival compared with no BCPR (adjusted proportion, 9.59%; 95% CI, 6.45-8.61). There was a significant interaction of BCPR with age. Among infants, conventional BCPR was associated with improved overall survival and neurologically favorable survival while compression-only CPR had similar outcomes to no BCPR. Conclusions and Relevance Bystander CPR is associated with improved outcomes in pediatric OHCAs. Improving the provision of BCPR in minority communities and increasing the use of conventional BCPR may improve outcomes for children with OHCA.

Ethical Challenges in Emergency Medical Services: Controversies and Recommendations

Emergency Medical Services (EMS) providers face many ethical issues while providing prehospital care to children and adults. Although provider judgment plays a large role in the resolution of conflicts at the scene, it is important to establish protocols and policies, when possible, to address these high-risk and complex situations. This article describes some of the common situations with ethical underpinnings encountered by EMS personnel and managers including denying or delaying transport of patients with non-emergency conditions, use of lights and sirens for patient transport, determination of medical futility in the field, termination of resuscitation, restriction of EMS provider duty hours to prevent fatigue, substance abuse by EMS providers, disaster triage and difficulty in switching from individual care to mass-casualty care, and the challenges of child maltreatment recognition and reporting. A series of ethical questions are proposed, followed by a review of the literature and, when possible, recommendations for management.

Part 9: First Aid 2015 International Consensus on First Aid Science With Treatment Recommendations

### Definition of First Aid The International Liaison Committee on Resuscitation (ILCOR) First Aid Task Force first met in June 2013. Comprising nominated members from around the globe appointed by each ILCOR member organization, the task force members first agreed to the goals of first aid and produced a definition of first aid as it might apply to the international setting. Task force members considered an agreed-upon definition essential for the subsequent development of research questions, evidence evaluation, and treatment recommendations. First aid is defined as the helping behaviors and initial care provided for an acute illness or injury. First aid can be initiated by anyone in any situation. A first aid provider is defined as someone trained in first aid who should The goals of first aid are to preserve life, alleviate suffering, prevent further illness or injury, and promote recovery. This definition of first aid addresses the need to recognize injury and illness, the requirement to develop a specific skill base, and the need for first aid providers to simultaneously provide immediate care and activate emergency medical services (EMS) or other medical care as required. First aid assessments and interventions should be medically sound and based on evidence-based medicine or, in the absence of such evidence, on expert medical consensus. The scope of first aid is not purely scientific, as both training and regulatory requirements will influence it. Because the scope of first aid varies among countries, states, and provinces, the treatment recommendations contained herein may need to be refined according to circumstances, need, and regulatory constraints. One difference between this 2015 definition and that used for the 2010 process is that the …

Part 9: First aid

### Definition of First Aid The International Liaison Committee on Resuscitation (ILCOR) First Aid Task Force first met in June 2013. Comprising nominated members from around the globe appointed by each ILCOR member organization, the task force members first agreed to the goals of first aid and produced a definition of first aid as it might apply to the international setting. Task force members considered an agreed-upon definition essential for the subsequent development of research questions, evidence evaluation, and treatment recommendations. First aid is defined as the helping behaviors and initial care provided for an acute illness or injury. First aid can be initiated by anyone in any situation. A first aid provider is defined as someone trained in first aid who should The goals of first aid are to preserve life, alleviate suffering, prevent further illness or injury, and promote recovery. This definition of first aid addresses the need to recognize injury and illness, the requirement to develop a specific skill base, and the need for first aid providers to simultaneously provide immediate care and activate emergency medical services (EMS) or other medical care as required. First aid assessments and interventions should be medically sound and based on evidence-based medicine or, in the absence of such evidence, on expert medical consensus. The scope of first aid is not purely scientific, as both training and regulatory requirements will influence it. Because the scope of first aid varies among countries, states, and provinces, the treatment recommendations contained herein may need to be refined according to circumstances, need, and regulatory constraints. One difference between this 2015 definition and that used for the 2010 process is that the …

Association of Mechanical Cardiopulmonary Resuscitation Device Use With Cardiac Arrest Outcomes: A Population-Based Study Using the CARES Registry (Cardiac Arrest Registry to Enhance Survival)

The use of mechanical cardiopulmonary resuscitation devices (mCPR) to deliver CPR has become more widespread, although a survival advantage has not been demonstrated in randomized, controlled trials.1–3 Little is known about real-world use of mCPR or the association with outcomes. CARES (Cardiac Arrest Registry to Enhance Survival), a US national registry of out-of-hospital cardiac arrest,4 was analyzed for adults with nontraumatic out-of-hospital cardiac arrest from January 2013 to December 2015. Patients treated with mCPR were compared with patients receiving manual CPR only. Time of arrest, time of first CPR, and timing of interventions were not reliably reported. However, patients had information about when return of spontaneous circulation (ROSC) occurred before or after advanced life support (ALS) measures. As part of a subgroup analysis, patients with ROSC before ALS were excluded because of the decreased likelihood of these patients receiving mCPR. The primary outcome of interest was neurologically favorable survival at hospital discharge, defined as a Cerebral Performance Category of 1 or 2. This project was deemed exempt from review by the Children’s Hospital of Philadelphia and University of Pennsylvania Institutional Review boards. Statistical analyses included the Student t test and χ2 test as appropriate. A multivariable logistic regression model was created with the use of stepwise addition to control for Utstein-style arrest characteristics, …

Medical Direction of Wilderness and Other Operational Emergency Medical Services Programs

Within a healthcare system, operational emergency medical services (EMS) programs provide prehospital emergency care to patients in austere and resource-limited settings. Some of these programs are additionally considered to be wilderness EMS programs, a specialized type of operational EMS program, as they primarily function in a wilderness setting (eg, wilderness search and rescue, ski patrols, water rescue, beach patrols, and cave rescue). Other operational EMS programs include urban search and rescue, air medical support, and tactical law enforcement response. The medical director will help to ensure that the care provided follows protocols that are in accordance with local and state prehospital standards, while accounting for the unique demands and needs of the environment. The operational EMS medical director should be as qualified as possible for the specific team that is being supervised. The medical director should train and operate with the team frequently to be effective. Adequate provision for compensation, liability, and equipment needs to be addressed for an optimal relationship between the medical director and the team.

Sternal fracture in the age of pan-scan

STUDY OBJECTIVE Widespread chest CT use in trauma evaluation may increase the diagnosis of minor sternal fracture (SF), making former teaching about SF obsolete. We sought to determine: (1) the frequency with which SF patients are diagnosed by CXR versus chest CT under current imaging protocols, (2) the frequency of surgical procedures related to SF diagnosis, (3) SF patient mortality and hospital length of stay comparing patients with isolated sternal fracture (ISF) and sternal fracture with other thoracic injury (SFOTI), and (4) the frequency and yield of cardiac contusion (CC) workups in SF patients. METHODS We analyzed charts and data of all SF patients enrolled from January 2009 to May 2013 in the NEXUS Chest and NEXUS Chest CT studies, two multi-centre observational cohorts of blunt trauma patients who received chest imaging for trauma evaluation. RESULTS Of the 14,553 patients in the NEXUS Chest and Chest CT cohorts, 292 (2.0%) were diagnosed with SF, and 94% of SF were visible on chest CT only. Only one patient (0.4%) had a surgical procedure related to SF diagnosis. Cardiac contusion was diagnosed in 7 (2.4%) of SF patients. SF patient mortality was low (3.8%) and not significantly different than the mortality of patients without SF (3.1%) [mean difference 0.7%; 95% confidence interval (CI) -1.0 to 3.5%]. Only 2 SF patient deaths (0.7%) were attributed to a cardiac cause. SFOTI patients had longer hospital stays but similar mortality to patients with ISF (mean difference 0.8%; 95% CI -4.7% to 12.0). CONCLUSIONS Most SF are seen on CT only and the vast majority are clinically insignificant with no change in treatment and low associated mortality. Workup for CC in SF patients is a low-yield practice. SF diagnostic and management guidelines should be updated to reflect modern CT-driven trauma evaluation protocols.

The Houston flood of 2001: The Texas Medical Center and lessons learned

Abstract Tropical Storm Allison was the deadliest and most-costly tropical or subtropical storm in recorded United States history. The world-renowned Texas Medical Center sustained approximately

The Use of Automated External Defibrillators in Infants: A Report From the American Red Cross Scientific Advisory Council

2 billion in damage, more than that experienced by any other medical community. In addition, decades of research performed by hundreds of scientists was destroyed. This article traces the unprecedented damage caused by this storm, focusing primarily on its direct and indirect effects on Texas Medical Center and its surrounding medical infrastructure. It also examines the storms impact on Texas Childrens Hospital, the only free-standing pediatric hospital in the city and one of only three tertiary-care hospitals in the city of Houston to remain open in the days following the storm.