S. Marshal Isaacs

The impact of a new CPR assist device on rate of return of spontaneous circulation in out-of-hospital cardiac arrest.

Objective. The San Francisco Fire Department deployed an automated, load-distributing-band chest compression device (AutoPulse, Revivant Corporation) to evaluate its function in a large urban emergency medical services (EMS) service. A retrospective chart review was undertaken to determine whether the AutoPulse had altered short-term patient outcome, specifically, return of spontaneous circulation (ROSC). Methods. AutoPulse cardiopulmonary resuscitation (A-CPR) was used by paramedic captains responding to adult cardiac arrests with an average ±SD response time of 15 ± 5 minutes. The primary endpoint was patient arrival to an emergency department with measurable spontaneous pulses. The manual CPR comparison group was case-matched for age, gender, initial presenting electrocardiogram rhythm, andthe number of doses of Advanced Cardiac Life Support medications as a proxy for treatment time. Matching was performed by an investigator blinded to outcome andtreatment group. Results. Sixty-nine AutoPulse uses were matched to 93 manual-CPR-only cases. A-CPR showed improvement in the primary outcome when compared with manual CPR with any presenting rhythm (A-CPR 39%, manual 29%, p = 0.003). When patients were classified by first presenting rhythm, shockable rhythms showed no difference in outcome (A-CPR 44%, manual 50%, p = 0.340). Outcome was improved with A-CPR in initial presenting asystole andapproached significance with pulseless electrical activity (PEA)(asystole: A-CPR 37%, manual 22%, p = 0.008; PEA: A-CPR 38%, manual 23%, p = 0.079). Conclusion. The AutoPulse may improve the overall likelihood of sustained ROSC andmay particularly benefit patients with nonshockable rhythms. A prospective randomized trial comparing the AutoPulse with manual CPR in the setting of out-of-hospital sudden cardiac arrest is under way.

THE ROLE OF INTRAOSSEOUS VASCULAR ACCESS IN THE OUT-OF-HOSPITAL ENVIRONMENT (RESOURCE DOCUMENT TO NAEMSP POSITION STATEMENT)

Thousands of critically ill emergency patients are treated in the out-of-hospital setting in the United States every year. In many patients intravenous (IV) therapy cannot be initiated because of inadequate access to peripheral veins. In some cases, this lack of vascular access may limit benefit of medications because of late administration.[[1]] Both speed andoverall success of vascular access are important when evaluating potential methodologies for their use in the out-of-hospital environment. Insertion of an IV cannula has been reported to require substantial time in the prehospital environment, with a recent study reporting an average successful intravenous line placement time of 4.4 ± 2.8 minutes.[[2]] In critically ill pediatric patients, vascular access may present substantial difficulties to the provide.[[3]] Intraosseous access may provide a significant time saving which may benefit many critically ill patients, both by decreasing the time to achieve access andby decreasing the time to administration of indicated medications.[[4]] Achieving rapid administration of medications may facilitate the care of critically ill patients.[[1]] Devices are now available that permit rapid, accurate access to the intraosseous space. Recent changes in the American Heart Associations resuscitation guidelines state that the intraosseous route should be the first alternative to difficult or delayed intravenous access.[[5]] With these considerations, the role of intraosseous vascular access in the out-of-hospital environment should be reemphasized.

The prehospital treatment of status epilepticus (PHTSE) study: design and methodology.

Status epilepticus is a neurological emergency that is typically first encountered and managed in the prehospital environment. Although aggressive pharmacological treatment of status epilepticus is well established in the emergency department and hospital settings, the relative risks and benefits of active therapy for status epilepticus in the prehospital setting are not known. The Prehospital Treatment of Status Epilepticus (PHTSE) study is a prospective, randomized, double-blind, placebo-controlled study designed to address the following aims: (1) to determine whether administration of benzodiazepines by paramedics is an effective and safe means of treating status epilepticus in the prehospital setting and whether this therapy influences longer-term patient outcome, (2) to determine whether lorazepam is superior to diazepam for the treatment of status epilepticus in the prehospital setting, and (3) to determine whether control of status epilepticus prior to arrival to the emergency department influences patient disposition. The initial phase of the PHTSE study began in January 1994 and was completed in February 1999 after the successful enrollment of 205 patients into the three treatment arms. In this paper, we describe the rationale for the conceptualization of the study and details of the study design and methodology, and emphasize some aspects of study implementation that are unique to research involving the emergency medical system.

Facilitating EMS Turnaround Intervals at Hospitals in the Face of Receiving Facility Overcrowding

The escalating national problem of oversaturated hospital beds andemergency departments (EDs) has resulted in serious operational impediments within patient-receiving facilities. It has also had a growing impact on the 9-1-1 emergency care system. Beyond the long-standing difficulties arising from ambulance diversion practices, many emergency medical services (EMS) crews are now finding themselves detained in EDs for protracted periods, unable to transfer care of their transported patients to ED staff members. Key factors have included a lack of beds or stretcher space, and, in some cases, EMS personnel are used transiently for ED patient care services. In other circumstances, ED staff members no longer prioritize rapid turnaround of EMS-transported patients because of the increasing volume andacuity of patients already in their care. The resulting detention of EMS crews confounds concurrent ambulance availability problems, creates concrete risks for delayed EMS responses to impending critical cases, andincurs regulatory jeopardy for hospitals. Communities should take appropriate steps to ensure that delivery intervals (time elapsing from entry into the hospital to physical transfer of patient care to ED staff) remain extremely brief (less than a few minutes) andthat they rarely exceed 10 minutes. While recognizing that the root causes of these issues will require far-reaching national health care policy changes, EMS andlocal government officials should still maintain ongoing dialogues with hospital chief administrators to mitigate this mutual crisis of escalating service demands. Federal andstate health officials should also play an active role in monitoring progress andcompliance.