Stan Feero

Succinylcholine-assisted intubations in prehospital care

Although endotracheal intubation is considered the optimal technique for airway management in critically ill patients, performance of this task in the prehospital setting is at times difficult due to increased masseter muscle tone, vocal cord spasm, or patient combativeness. Use of short-acting paralyzing agents by paramedics to facilitate intubation in these situations is an uncommon practice. We report the recent experience of an emergency medical service system that has used succinylcholine (SUX) for more than ten years. We reviewed prehospital patient intubations for two years; 215 patients were intubated by paramedics without the use of SUX and 95 patients were intubated with the use of SUX. The patient group intubated with SUX was characterized by a greater percentage of women (48% vs 35%; P less than .05), a higher mean Glasgow Coma Scale score (8.6 vs 3.4), fewer intubations for cardiac arrest (3% vs 81%), and more hospital survivors (58% vs 24%; P less than .005). The groups were not different with respect to mean age or frequency of trauma. Paramedics chose to use SUX in 69% of nonarrested patients requiring intubation. SUX-assisted intubation was used most often for the indications of airway protection and respiratory distress. Review of hospital records showed no difference between the groups for frequency of either aspiration pneumonia or mechanical ventilation in patients surviving to hospital admission. No patient receiving SUX required emergency cricothyrotomy, nor was esophageal intubation noted in either group. Succinylcholine-assisted intubation was used safely and selectively by the paramedics in this EMS system to permit airway control and ventilation of patients with more difficult intubations.

Does out-of-hospital EMS time affect trauma survival?

To determine if out-of-hospital emergency medical services (EMS) time intervals are associated with unexpected survival and death in urban major trauma, a retrospective review was conducted of major trauma cases entered into an urban trauma system by an EMS system during a one-year period. Patients with unexpected death or unexpected survival were identified using TRISS methodology. The EMS response, on-scene time, transport time, and total EMS out-of-hospital time intervals were compared for the two groups using the unpaired t test (two-tailed analysis). Of 848 major trauma cases, there were 13 (1.5%) unexpected survivors and 20 (2.4%) unexpected deaths. Of those patients with complete EMS times, the mean out-of-hospital response time interval was significantly shorter for the unexpected survivors (3.5 +/- 1.2 minutes v 5.9 +/- 4.3 minutes; P = .04). The mean EMS on-scene time interval (7.8 +/- 4.1 minutes v 11.6 +/- 6.5 minutes; P = .06) and the mean transport time interval (9.5 +/- 4.4 minutes v 11.7 +/- 4.0 minutes; P = .17) also favored the unexpected survivor group. Overall, the total EMS time interval was significantly shorter for unexpected survivors (20.8 +/- 5.2 minutes v 29.3 +/- 12.4 minutes; P = .02). It was concluded that a short overall out-of-hospital time interval may positively affect patient survival in selected urban major trauma patients.

Factors contributing to paramedic onscene time during evaluation and management of blunt trauma

Prehospital patient management decisions are complex because the traumatized patient population is heterogeneous with respect to demographics, mechanism of injury, physiological response to injury, and time from injury to medical care. One hundred and nine blunt trauma patient evaluations by paramedics in a county-wide semirural emergency medical services (EMS) system were analyzed to determine paramedic time on the scene and the factors that might influence onscene time. Onscene time linearly correlated with a prolonged transport time. Hemodynamic and respiratory dysfunction were also associated with increased onscene time. Mean onscene time was not significantly different between high (greater than 13) and low (less than or equal to 13) trauma score (TS) groups, although patients with low TS did receive more interventions (more intravenous lines, more frequent intubation, and more frequent pneumatic antishock garment use). Similar results were found when high (greater than 10) and low (less than or equal to 10) Glasgow Coma Scale (GCS) groups were compared. The correlation of emergency department TS with initial prehospital TS and onscene time demonstrated a small improvement in TS with increasing onscene time for the patient with an initial TS greater than or equal to 13. However, patient groups with either a low TS or a low GCS score showed no significant improvement in TS with increasing onscene time. Without a strict management algorithm, paramedics use a variety of cues to guide their actions during the onscene management of blunt trauma. Future studies should address the impact of strict management algorithms on onscene time and ultimate patient outcome.

Intracity Regional Demographics of Major Trauma

Abstract Study objective: To report intracity, regional trauma, geographic, and demographic factors affecting risk of major intentional versus nonintentional trauma. Design: One-year retrospective analysis of trauma-registry and census-tract databases. Setting: Urban trauma system with patient entry by emergency medical services personnel. Participants : Major trauma cases grouped by presumed intent to injure. Interventions: We examined age- and sex-adjusted trauma rates for seven geographic intracity regions (comprising of 144 census tracts) to identify associations with population density, median household income, and race data. Rates and risk factors for intentional versus nonintentional trauma were compared. Results: Two hundred fifty-seven intentional and 575 nonintentional major trauma system cases were identified. Both intentional (relative risk [RR], 7.0; 95% CI, 5.1 to 9.7) and nonintentional (RR, 2.7; CI, 2.3 to 3.3) injury populations were predominately male. Intentional-trauma victims were disproportionately nonwhite (RR, 4.1; CI, 3.2 to 5.1). The 15- to 24-year-old (RR, 20.3; CI, 16.7 to 24.6) and 25- to 34-year-old (RR, 15.3; CI, 12.7 to 18.4) age groups were more likely to sustain intentional trauma than the 0- to 14-year-old age group. Regional differences in occurrence rates were most pronounced for intentional trauma; 52% of all intentional traumas occurred within a small area of 14 census tracts. Residents in low median income households were more commonly subject to intentional injury. Conclusion: Different demographic features affect intentional and nonintentional major trauma in Portland, Oregon. These features can be used to guide emergency medical services planning and injury-prevention measures. [Reero S, Hedges, JR, Simmons E, Irwin L:Intracity regional demographics of major truma. Ann Emerg Med June 1995; 25:788-793.]

Prehospital Transcutaneous Cardiac Pacing for Symptomatic Bradycardia

We studied patients with symptomatic bradycardia to determine the importance of presenting hemodynamic status and prehospital transcutaneous cardiac pacing (TCP) upon patient survival. Of 51 patients with witnessed cardiovascular decompensation and initial bradycardia, 27 (53%) received TCP. There were no significant differences between the paced patients and those without TCP for mean times from collapse until cardiopulmonary resuscitation, paramedic arrival and a paceable rhythm, or from paramedic arrival until a paceable rhythm. Overall, emergency department arrival with a palpable pulse (26% in paced vs 13% in nonpaced group; P = 0.20) and survival to hospital discharge (15% in paced vs 0% nonpaced group; P = 0.07) tended to be better for the paced group. No patient without a palpable pulse on paramedic arrival survived to leave the hospital. Of patients with a palpable pulse upon paramedic arrival, survival to hospital discharge was greater for the paced group (80% in paced vs 0% in nonpaced group; P = 0.024). TCP appears to be most beneficial in those patients with bradycardia who have a palpable pulse when first seen.

Intra-City Regional Demographics of Major Trauma

STUDY OBJECTIVE To report intracity, regional trauma, geographic, and demographic factors affecting risk of major intentional versus nonintentional trauma. DESIGN One-year retrospective analysis of trauma-registry and census-tract databases. SETTING Urban trauma system with patient entry by emergency medical services personnel. PARTICIPANTS Major trauma cases grouped by presumed intent to injure. INTERVENTIONS We examined age- and sex-adjusted trauma rates for seven geographic intracity regions (comprising of 144 census tracts) to identify associations with population density, median household income, and race data. Rates and risk factors for intentional versus nonintentional trauma were compared. RESULTS Two hundred fifty-seven intentional and 575 nonintentional major trauma system cases were identified. Both intentional (relative risk [RR], 7.0; 95% CI, 5.1 to 9.7) and nonintentional (RR, 2.7; CI, 2.3 to 3.3) injury populations were predominately male. Intentional-trauma victims were disproportionately nonwhite (RR, 4.1; CI, 3.2 to 5.1). The 15- to 24-year-old (RR, 20.3; CI, 16.7 to 24.6) and 25- to 34-year-old (RR, 15.3; CI, 12.7 to 18.4) age groups were more likely to sustain intentional trauma than the 0- to 14-year-old age group. Regional differences in occurrence rates were most pronounced for intentional trauma; 52% of all intentional traumas occurred within a small area of 14 census tracts. Residents in low median income households were more commonly subject to intentional injury. CONCLUSION Different demographic features affect intentional and nonintentional major trauma in Portland, Oregon. These features can be used to guide emergency medical services planning and injury-prevention measures.