Ronald N. Roth

Hyponatremia in runners requiring on-site medical treatment at a single marathon

STUDY OBJECTIVE Literature reports indicate an increasing number of cases of hyponatremia in athletes participating in moderate endurance events such as standard marathons. In this study, we evaluated the incidence of hyponatremia in marathon finishers requiring medical treatment on-site and attempted to assess the contribution of fluid type ingested and nonsteroidal antiinflammatory drug (NSAID) use to the development of hyponatremia. METHODS We examined a prospective, convenience sample of runners requiring intravenous hydration at the final medical tent of a standard marathon course and a comparison group of finishers who did not require intravenous hydration. After giving informed consent, subjects had blood drawn and answered a questionnaire regarding fluid intake on the course and NSAID use before the race. Blood samples were analyzed on-site for serum sodium values as well as other hematologic parameters. RESULTS Fifty-one subjects requiring intravenous hydration as well as 11 subjects who did not were enrolled. Three subjects (5.6%; 95% CI, 0-11.9%; missing = 8) in the intravenous hydration group had serum sodium less than 130 mEq/L. None of the three runners suffered neurologic or pulmonary consequences and only one required overnight hospital admission for hydration. The small number of hyponatremic subjects precluded the analysis of the role of fluid type or NSAID use in the development of hyponatremia or the development of a model for prediction. CONCLUSION This study found a 5.6% incidence of hyponatremia in marathon runners requiring medical treatment.

Carbon monoxide ... the silent killer with an audible solution.

Carbon monoxide (CO) is responsible for more poisoning fatalities each year than any other toxic agent. The often insidious nature of the symptom progression and its ability to imitate many common illnesses may result in the failure to diagnose a potentially fatal outcome. CO detectors equipped with an audible alarm can alert potential victims of CO poisoning before toxic sequelae develop. A study was conducted in which all calls to 911 concerning a CO detector in alarm or regarding possible CO poisoning were investigated by a paramedic crew; 101 possible CO exposures were investigated. CO detectors with audible alarms were the genesis of 59.4% of the calls. Detectable CO levels were found in 69.3% of the investigations, and 80% of the homes with detectors had verifiable CO concentrations. The mean CO concentration in homes with detectors was 18.6 ppm, compared with 96.6 ppm when no detector was available; 63.4% of the victims with no alarm were symptomatic, compared with 13.3% of victims with alarms. CO detectors with audible alarms were effective in alerting the potential victims of CO poisoning to its presence. Persons with CO detectors were less likely to become symptomatic from a CO exposure than those who did not have CO detectors.

Agreement between rectal and tympanic membrane temperatures in marathon runners.

STUDY OBJECTIVE To determine the agreement between rectal temperature and infrared tympanic membrane temperatures in marathon runners presenting to a field hospital at the finish line. METHODS The subjects of this prospective, blinded, controlled study were runners 18 years or older who were triaged to the acute care medical area at the finish line for suspected hypothermia, hyperthermia, dehydration, or altered mental status. Rectal and tympanic temperatures were measured simultaneously in all subjects for whom rectal temperature measurement had been deemed necessary and recorded on separate data cards. RESULTS Of the 239 runners treated in the acute care medical area, 37 required rectal temperature measurement and were enrolled in the study. The mean rectal temperature was 38.45 degrees +/- 1.20 degrees C (range, 35.9 degrees to 41.5 degrees C). The mean tympanic membrane temperature was 37.81 degrees +/- 95 degrees C (range, 36.3 degrees to 40.4 degrees C). Pearsons correlation coefficient revealed a moderate correlation (r = .6902, P = .00023). The mean temperature difference between the two thermometers, mean rectal minus mean tympanic membrane, was .64 degrees C (95% confidence interval, .35 degrees to .93 degrees C). Sixty-Two percent of the tympanic membrane readings were within 1 degree C of their rectal counterparts. Agreement ranged from 1.16 degrees (+2 SD) to -2.95 degrees (-2 SD). The 95% confidence interval was 1.67 degrees to -2.95 degrees C. CONCLUSION We were able to demonstrate only a moderate correlation between the two thermometer readings, with a wide spread between the limits of agreement. This spread could be clinically significant and therefore limits the usefulness of tympanic temperature in the marathon race setting. Because of the potentially large and clinically significant differences in rectal and tympanic temperatures and the limitations inherent in our study, we cannot endorse the use of tympanic temperature in the setting of a marathon event.

Alternate Airways in the Prehospital Setting (Resource Document to NAEMSP Position Statement)

In the United States, advanced level rescuers often use endotracheal intubation (ETI) to provide oxygenation and ventilation to apneic or hypoventilating patients. Alternate airways are devices that facilitate oxygenation and ventilation without the use of an endotracheal tube (Table 1). Other terms used to describe an alternate airway include rescue airway device, alternative airway, secondary airway, failed airway device, difficult airway device, salvage airway and backup airway, among others. Although rescuers typically use alternate airways when ETI is not feasible, these devices are occasionally used as the primary airway device. This resource document reviews the rationale and data supporting the availability and use of alternate airways in prehospital airway care.

Identification of Adverse Events in Ground Transport Emergency Medical Services

The purpose of this study was to develop a method to define and rate the severity of adverse events (AEs) in emergency medical services (EMS) safety research. They used a modified Delphi technique to develop a consensus definition of an AE. The consensus definition was as follows: “An adverse event in EMS is a harmful or potentially harmful event occurring during the continuum of EMS care that is potentially preventable and thus independent of the progression of the patient’s condition.” Physicians reviewed 250 charts from 3 EMS agencies for AEs. The authors examined physician agreement using κ, Fleiss’s κ, and corresponding 95% confidence intervals (CIs). Overall physician agreement on presence of an AE per chart was fair (κ = 0.24; 95% CI = 0.19, 0.29). These findings should serve as a basis for refining and implementing an AE evaluation instrument.

Management of prehospital seizure patients by paramedics.

Background. Seizure patients are frequently encountered in the prehospital environment andhave the potential to need advanced interventions, though the utility of advanced life support (ALS) interventions in many of these patients has not been proven. Objective. Our goals were to assess the management of prehospital seizure patients by paramedics in an urban EMS system with an existing ALS-based prehospital seizure protocol andto assess characteristics andshort-term outcomes that may aid in addressing the utility of specific ALS interventions. Methods. This was a retrospective study of 97 EMS cases with the chief complaint of seizure. Prehospital records were reviewed for patient andevent characteristics, including past seizure history, seizure timing, level of consciousness, on-scene andtransport times, andEMS interventions. Emergency department (ED) records were reviewed for recurrence of seizure activity, ED evaluation, anddisposition. Data were analyzed using descriptive statistics andStudent t-test. Results. Of 87 patients meeting the protocol inclusion criteria for all ALS interventions, 11 (12.6%) received cardiac monitoring, 55 (63.2%) had intravenous (IV) access attempted, and56 (64.4%) had blood glucose determination. Average on-scene time was 5.9 minutes longer if IV access was attempted (p = 0.001), though transport times were not significantly different (11.6 versus 11.3 minutes, respectively; p = 0.851). Additional seizure activity occurred in the prehospital and/or ED settings in 28 patients (28.9% of all cases), including 17 in the prehospital setting and15 in the ED. Diazepam was administered by EMS for half of the eight (8.2%) patients who had seizures lasting more than 1 minute, while the remainder had seizures that were focal or spontaneously resolved. Conclusion. This study showed a lower-than-anticipated level of compliance with an ALS-based prehospital seizure protocol, though patient-specific care appeared appropriate. Prehospital seizure patients have the potential for seizure recurrence andmay benefit from focused ALS interventions, but their heterogeneity makes uniform protocols difficult to develop andfollow.

Measuring Adverse Events in Helicopter Emergency Medical Services: Establishing Content Validity

Abstract Introduction. We sought to create a valid framework for detecting adverse events (AEs) in the high-risk setting of helicopter emergency medical services (HEMS). Methods. We assembled a panel of 10 expert clinicians (n = 6 emergency medicine physicians and n = 4 prehospital nurses and flight paramedics) affiliated with a large multistate HEMS organization in the Northeast US. We used a modified Delphi technique to develop a framework for detecting AEs associated with the treatment of critically ill or injured patients. We used a widely applied measure, the content validity index (CVI), to quantify the validity of the frameworks content. Results. The expert panel of 10 clinicians reached consensus on a common AE definition and four-step protocol/process for AE detection in HEMS. The consensus-based framework is composed of three main components: (1) a trigger tool, (2) a method for rating proximal cause, and (3) a method for rating AE severity. The CVI findings isolate components of the framework considered content valid. Conclusions. We demonstrate a standardized process for the development of a content-valid framework for AE detection. The framework is a model for the development of a method for AE identification in other settings, including ground-based EMS.

C OMPARISON OF T IMES TO I NTUBATE A S IMULATED T RAUMA P ATIENT IN T WO P OSITIONS

Background. The nature of the trauma patients injuries may compromise the airway and ultimately lead to death or neurological devastation. The same injuries complicate protecting the airway in these patients by preventing manipulation of the cervical spine for direct laryngoscopy. A recent study has shown that misplaced endotracheal tubes occur significantly more often in trauma patients than in medical patients. Objectives. The authors hypothesized that elevating the long spine board would reduce the amount of time required for paramedics to intubate a simulated trauma patient. Methods. Paramedics from an urban emergency medical services division were given up to two opportunities to intubate a manikin in a type I ambulance in each of two positions in random order: supine and with the head elevated. The manikin was secured to a long spine board with three straps, a semi-rigid cervical collar, and a cervical immobilization device. An investigator maintained cervical spine alignment and provided cricoid pressure. The elevated position was accomplished by raising the head of the stretcher 27°, resulting in 7° of spine board elevation. Each attempt was timed. If the first attempt was unsuccessful, the times for both the first and second attempts were totaled to determine the total time required for intubation. Times for successful intubation in each position were compared with a Mann-Whitney test. First-attempt success rates for each position were compared with χ2 analysis. Multinomial regression was used to determine whether experience, paramedic height, or previous intubation success influenced intubation time in either position. Results. Fifty-five paramedics provided informed consent and completed the study. Average time to intubate the supine manikin was significantly longer than needed to intubate the head-elevated manikin (35.6 ± 19.0 seconds vs 27.9 ± 12.8 seconds, p = 0.025). The manikin was successfully intubated on the first attempt 84% in the supine position and 95% in the head-elevated position (p = 0.200). Regression analysis identified intubation position as the only significant predictor of intubation time (p = 0.007). Conclusions. Modest elevation of the head of an immobilized patient appears to allow more rapid intubation. With the spine board properly secured to the stretcher, this technique potentially offers improved intubation time without additional cost or equipment.

Resident Field Response in an Emergency Medicine Prehospital Care Rotation

Abstract Background. Emergency medical services (EMS) is an important component of emergency medicine residency curricula. For over 20 years, residents at a university-affiliated program have staffed a physician response vehicle and responded to selected calls in an urban EMS system with online faculty backup. Objectives. To describe the prehospital educational experience and patient care provided through this unique program and to assess residents’ perceptions. Methods. This was a three-year retrospective study of patient care records for all prehospital resident responses. Information obtained included complaint, disposition, procedures performed, and medications administered. The number of EMS radio consultations provided by residents during this rotation was also sought. We surveyed 43 current and recently graduated residents to assess their perceptions of this experience. Results. Residents treated 1,434 patients during 1,381 scene responses (16.7 field patient contacts per resident-year). Complaints included cardiac arrest (788, 55.0%) and neurologic (230, 16.0%), traumatic (194, 13.5%), respiratory (144, 10.0%), and other cardiac (40, 2.8%) emergencies. Most patients (1,022; 71.3%) were transported to the hospital, including 82 of 143 patients (57.3%) who initially refused EMS transport. Residents performed procedures on 546 responses (39.5%), including 123 successful intubations, 115 central lines, 43 peripheral (IV) lines, and 10 intraosseous lines. EMS radio consultation records were available for only the second half of the study period. Residents provided 11,583 consultations during this one-and-a-half-year period (264 radio consultations per resident-year). Of the 40 returned surveys (93.0%), autonomy (n = 21), medical decision making (n = 10), and management of high-acuity patients (n = 7) were the most important perceived benefits of this program. Conclusion. Our prehospital training program incorporates emergency medicine residents as in-field physicians and allows hands-on opportunity to provide patient care for a variety of conditions in the EMS environment, as well as extensive experience in online medical direction. The trainees believed it had a strong positive impact on their acquisition of important emergency medicine abilities.

HORNER'S SYNDROME IN THE EMERGENCY DEPARTMENT

We present a case of a 47-year-old female who was followed for 7 months with complaints of musculoskeletal pain involving the shoulder and scapula until she presented to the emergency department with Horners syndrome and was diagnosed as having a superior pulmonary sulcus tumor. A review of the literature shows that although such tumors are a frequent cause of Horners syndrome there are numerous other benign as well as malignant causes of Horners syndrome. The differential diagnosis can be significantly narrowed by a knowledge of the anatomy and a careful physical examination. We present the anatomy, pathophysiology, differential diagnosis, and evaluation of patients who present to the emergency department with Horners syndrome.