Objectives: Recognizing the increasing age and comorbid conditions of patients admitted to our trauma service, we embedded a hospitalist on the trauma service at our level 1 trauma center. This program was initiated in January of 2013. This study was designed to investigate differences in outcomes between trauma patients that received care from the trauma hospitalist (THOSP) program and similarly medically complex trauma patients that did not receive THOSP care. Methods: There were 566 patients co-managed with THOSP between Dec 2013 and Nov 2014. These patients were matched (1:2) with propensity scores to a contemporaneous control group based on age, ISS, and comorbid conditions. Outcomes examined included: mortality, trauma-related readmissions, upgrades to the ICU, hospital length of stay (LOS), the development of in-hospital complications, and the frequency of obtaining medical subspecialist consultation. Differences in outcomes were compared with Mann-Whitney or Chi-Square tests as appropriate. Results: High quality matching resulted in the loss of 97 THOSP patients for the final analysis. Table 1 shows the balance between the two groups after matching. While there was a one day increase in hospital LOS, and an increase in upgrades to the ICU, there was a reduction in mortality, trauma-related readmissions, and the development of renal failure after implementation of the THOSP program (Table 2). Implementation of this program made no significant difference in the frequency of cardiology, nephrology, neurology, or endocrinology consultations. There was also no difference in the development of the complications of venous thromboembolism, pneumonia, stroke, urinary tract infection, bacteremia, or alcohol withdrawal. Conclusions: Our study provides evidence that embedding a hospitalist on the trauma service reduces mortality and trauma-related readmissions. A reason for these improved outcomes may be related to THOSP 'vigilance'. Evidence Type and Level: Therapeutic/Care Management, Level III (C) 2016 Lippincott Williams & Wilkins, Inc.
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Πέμπτη 31 Μαρτίου 2016
The role of laparoscopy in management of stable patients with penetrating abdominal trauma and organ evisceration.
Background: Organ evisceration following penetrating abdominal trauma (PAT) carries a high rate of significant intraabdominal injuries. There is uniform agreement that organ evisceration warrants immediate laparotomy. Nonoperative management of stable asymptomatic patients with evisceration is associated with a high failure rate. Most authors exclude patients with organ evisceration from laparoscopic management. The aim of this study was to determine the significance of organ evisceration in stable patients with PAT and to assess the feasibility of laparoscopic management of this group. Material and methods: Intraoperative findings, performed surgery and complications in stable patients who underwent laparoscopy for PAT and evisceration between January 2012 and December 2014 were retrospectively analyzed. All unstable patients underwent laparotomy and were excluded. Results: A total of 189 stable patients were treated with laparoscopy for PAT. Thirty nine (20.6%) patients had organ evisceration; 37 were due to stab and two patients due to gunshot wounds. Fifteen patients had bowel evisceration and 24 had omental evisceration. In total 25 (64%) patients had significant injuries (colon, small bowel, etc.) and required therapeutic laparoscopy. The rate of therapeutic laparoscopy was 73% in patients with bowel evisceration and 58% in patients with omental evisceration. This difference was not statistically significant. The most commonly injured organ was the small bowel. The small bowel repair, resection and anastomosis were the most commonly performed procedures. We did not have any missed injuries. There were neither conversions nor significant complications in the postoperative period. Fourteen patients avoided nontherapeutic laparotomy. Conclusion: Organ evisceration in stable patients with PAT is associated with a high rate of significant intraabdominal injuries and mandates abdominal exploration. Laparoscopic management is feasible, has a high accuracy in identifying intraabdominal injuries, provides all benefits of minimal invasive surgery and avoids nontherapeutic laparotomy. Level of evidence: V Study type: Therapeutic, Diagnostic test (C) 2016 Lippincott Williams & Wilkins, Inc.
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Improving Geriatric Trauma Outcomes: A Small Step Toward a Big Problem.
Background: Due to the unique physiology and co-morbidities of injured geriatric patients, specific interventions are needed to improve outcomes. The purpose of this study was to assess the effect of a change in triage criteria for injured geriatric patients evaluated at an ACS Level I trauma center. Methods: As of October 1, 2013, all injured patients >= 70 years of age were mandated to have the highest level trauma activation upon emergency department arrival regardless of physiology or mechanism of injury. Patients admitted prior to that date were designated PRE; those admitted after were designated POST. The study period was from October 1, 2011 through April 30, 2015. Data collected included demographics, mechanism of injury, hypotension on admission, comorbidities, Injury Severity Score (ISS), emergency department length of stay (ED LOS), complications, and mortality. Bivariate and multivariable analyses were used to compare outcomes between the study groups (p
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The Impact of Acute Coagulopathy on Mortality in Pediatric Trauma Patients.
Background: Traumatic coagulopathy (TC) occurs in 24-38% of adults and is associated with up to a 6-fold increase in mortality. This study's purpose is to determine the incidence of pediatric TC and its impact on mortality. Methods: A retrospective review (2004-2009) of all trauma patients from our Level I Trauma Center was performed. Coagulopathy was defined as an INR >= 1.5 or aPTT > 36 seconds or platelets =16 years). Results: A total of 20,126 patients were identified (7.6% pediatric, 92.4% adult). Mean age +/- SD was 8.7 +/- 4.8 years for pediatric patients and 37.6 +/- 16.7 years for adults. The incidence of admission coagulopathy was lower in children (5.8% vs. 8.4%, p
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DERIVATION AND VALIDATION OF A NOVEL EMERGENCY SURGERY ACUITY SCORE (ESAS).
Background: There currently exists no pre-operative risk stratification system for Emergency Surgery (ES). We sought to develop an Emergency Surgery Acuity Score (ESAS) that helps predict perioperative mortality in ES patients. Methods: Using the 2011 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (derivation cohort), we identified all surgical procedures that were classified as "emergent". A three step methodology was then performed. First, multiple logistic regression models were created to identify independent predictors (e.g. patient demographics, co-morbidities, and pre-operative laboratory variables) of 30-day mortality in ES. Second, based on the relative impact of each identified predictor (i.e. Odds Ratio), using weighted averages, a novel score was derived. Third, using the 2012 ACS-NSQIP database (validation cohort), the score was validated by calculating its c-statistic and evaluating its ability to predict 30-day mortality. Results: From 280,801 NSQIP cases, 18,439 ES cases were analyzed, of which 1,598 (8.7%) resulted in death at 30 days. The multiple logistic regression analyses identified 22 independent predictors of mortality. Based on the relative impact of these predictors, ESAS was derived with a total score range of 0-29. ESAS had a c-statistic of 0.86; the probability of death at 30-day gradually increased from 0% to 36% then 100% at scores of 0, 11 and 22, respectively. In the validation phase, 19,552 patients were included, the mortality rate was 7.2% and the ESAS c-statistic stayed at 0.86. Conclusions: We have therefore developed and validated a novel score, ESAS, that accurately predicts mortality in ES patients. Such a score could prove useful for: 1) pre-operative patient counseling; 2) identification of patients needing close postoperative monitoring; and 3) risk-adjustment in any efforts at benchmarking the quality of ES. Level of Evidence: III Study Type: Prognostic and Epidemiological (C) 2016 Lippincott Williams & Wilkins, Inc.
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Utility of computed tomography imaging of the cervical spine in trauma evaluation of ground level fall.
BACKGROUND: CT of the cervical spine is routinely ordered for low-risk mechanisms of injury, including ground level fall (GLF). Two commonly employed clinical decision rules (CDRs) to guide C-spine imaging in trauma are the National Emergency X-Radiography Utilization Study (NEXUS) and the Canadian Cervical Spine Rule for Radiography (CCR). METHODS: Retrospective cross-sectional study of 3,753 consecutive adult patients presenting to an urban Level I ED who received C-spine CT scans were obtained over a six month period. The primary outcome of interest was prevalence of cervical spine fracture. Secondary outcomes included fracture stability, appropriateness of imaging by NEXUS and CCR criteria, and estimated radiation dose-exposure and costs associated with C-spine imaging studies. RESULTS: Of the 760 patients meeting inclusion criteria, seven cervical spine fractures were identified (0.92% +/- 0.68%). All fractures were identified by NEXUS and CCR criteria with 100% sensitivity. Of all these imaging studies performed, only 68% met NEXUS indications for imaging (49% met CCR indications). Cervical spine CT scans in patients not meeting CDR indications were associated with costs of $30-43,000 by NEXUS ($29-71,000 by CCR) in this single center during the six-month study period. CONCLUSIONS: For GLF, C-spine CT is over-utilized. The consistent application of CDR criteria would reduce annual nation-wide imaging costs in the US by $13-19 million based on NEXUS ($12-31 million based on CCR), and would reduce population radiation dose-exposure by 0.8-1.1 million mGy based on NEXUS ( 0.7-1.9 million mGy based on CCR) if applied across all level I trauma centers. Greater use of evidence-based CDRs plays an important role in facilitating ED patient management and reducing system-wide radiation dose exposure and imaging expenditures. LEVEL of EVIDENCE: Level II Diagnostic Test (C) 2016 Lippincott Williams & Wilkins, Inc.
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Pediatric gunshot wound recidivism: Identification of at-risk youth.
Background: Although penetrating injury is the most common reason for pediatric trauma recidivism, there is a paucity of literature specifically looking at this population. The objective of this study was to identify those in the pediatric community at the highest levels of risk for suffering GSW on multiple occasions. Methods: A retrospective review querying our urban level 1 trauma database was performed. Patients aged 0-18 sustaining GSW from 2000 to 2011 were selected. This was further refined to include those who returned to the hospital for another firearm injury. Demographic data, including age of initial and subsequent presentation, gender, race, zip code, home address, and disposition were compiled. Results: Over the 12 year study period 896 pediatric patients were discharged from the hospital after initial firearm injury with subsequent 8.8 % recidivism rate. All recidivists were male with and 86% were 16-18 at the time of first injury. The subsequent incident occurs within the first year, two years, or three years 32%, 53% and 66% of the time respectively. 9 individuals in our study group suffered GSW on three separate occasions with a mortality rate of 22%. Regarding the domicile, 53 % of the patients were located in a 3 square mile area containing four public high schools. Conclusion: Utilizing demographic data we have been able to identify a at-risk population where there is a greater than a one in twelve chance of getting shot multiple times. Utilization of this type of demographic data can help target those at highest risk by allocating resources that can have the greatest impact on this societal burden. Level Of Evidence: Level 3 Prognostic (C) 2016 Lippincott Williams & Wilkins, Inc.
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Performance improvement and patient safety program (PIPS) guided quality improvement initiatives can significantly reduce CT imaging in pediatric trauma patients.
Background: Morbidity and mortality of cervical spine (C-Spine) injury in pediatric trauma patients is high, necessitating quick and accurate diagnosis. Best practices emphasize minimizing radiation exposure through decreased reliance on computed tomography (CT), instead using clinical assessment, physical examination and alternate imaging techniques. We implemented an institutional performance improvement and patient safety program (PIPS) initiative for C-Spine clearance in 2010 due to high rates of CT scans among pediatric trauma patients. Methods: A retrospective review of pediatric trauma patients, ages 0-14, in the pre- and post-PIPS implementation periods was conducted. Rates of C-Spine CT, overall CT, other imaging modalities, radiation exposure, patient characteristics and injury severity were compared, and compliance with PIPS protocol was reviewed. Results: Patient characteristics and injury severity were similar pre- and post-PIPS implementation. C-Spine CT rates decreased significantly between groups (30% v 13%, p
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Early initiation of extracorporeal membrane oxygenation improves survival in adult trauma patients with severe acute respiratory distress syndrome.
Introduction: Usage of extracorporeal membrane oxygenation (ECMO) in the trauma population has been reported to have a mortality benefit in patients with severe refractory hypoxic respiratory failure. This study compares the early initiation of ECMO for management of severe Acute Respiratory Distress Syndrome (ARDS) versus a historical control immediately preceding the use of ECMO for trauma patients. Methods: A retrospective study was conducted at a single verified Level I trauma center. The study population was limited to trauma patients diagnosed with severe ARDS using the Berlin definition (PaO2/FiO2 [P/F] ratio
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The transforming power of early career acute care surgery research scholarships on academic productivity.
Background: Over 75% of respondents to an Eastern Association for the Surgery of Trauma (EAST) survey felt that barriers to research had increased and that acute care surgeon (ACS) academic productivity had decreased. Recent data confirm this impression and show lower academic productivity of junior ACS faculty compared to peers in other general surgical fields. The purpose of this study was to determine if early career ACS research scholarships are associated with improved ACS academic productivity. Methods: Faculty data at the top 55 National Institutes of Health (NIH) funded departments of surgery (TOP55) was obtained using SCOPUS, NIH, department and professional society databases. Academic productivity was measured using total publications (PUBS), citations and the h-index. Scholarship recipients from the American Association for the Surgery of Trauma (AAST) and EAST were identified (RECIPIENTS). Results: 4,101 surgical faculty (8.3% ACS) in TOP55 and 85 RECIPIENTS were identified. After merging, 34 RECIPIENTS (40%) were current faculty at a TOP 55 and 24 of those (71%) were ACS faculty. RECIPIENTS had higher median PUBS compared to NON-RECIPIENTS at assistant and associate ranks, but not at full professor rank. For all ranks, RECIPIENTS were more likely to have NIH funding compared to NONRECIPIENTS (33% vs 11% p
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Are Frailty Markers Associated with Serious Thoracic and Spinal Injuries Among Motor Vehicle Crash Occupants?.
Background: While age is a known risk factor in trauma, markers of frailty are growing in their use in the critically ill. Frailty markers may reflect underlying strength and function more than chronologic age, as many modern elderly patients are quite active. However, the optimal markers of frailty are unknown. Methods: A retrospective review of The Crash Injury Research and Engineering Network (CIREN) database was performed over a 11 year period. CT images were analyzed for multiple frailty markers, including: sarcopenia determined by psoas muscle area (PMA), osteopenia determined by Houndsfeld units (HU) of lumbar vertebrae, and vascular disease determined by aortic calcification (AC). Results: Overall 202 patients were included in the review, with a mean age of 58.5 years. Median Injury Severity Score (ISS) was 17. Sarcopenia was associated with severe thoracic injury (62.9% vs. 42.5%, p=0.03). In multivariable analysis controlling for crash severity, sarcopenia remained associated with severe thoracic injury (p=0.007) and osteopenia was associated with severe spine injury (p=0.05). While age was not significant in either multivariable analysis, the association of sarcopenia and osteopenia with development of serious injury was more common with older age. Conclusions: Multiple markers of frailty were associated with severe injury. Frailty may more reflect underlying physiology and injury severity than age, although age is associated with frailty. Level of Evidence: Prognostic and epidemiologic study, level IV. (C) 2016 Lippincott Williams & Wilkins, Inc.
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Improvement in quality of life among violently injured youth following a brief intervention.
Background: Youth directly exposed to violence are at risk for experiencing elevated rates of emotional and behavioral problems, re-victimization, and becoming future perpetrators of violence. Violence intervention and prevention programs throughout the country attempt to alleviate some of this burden. To date, outcomes have been positive but largely qualitative. Patient-reported outcomes offer objective measures to evaluate well-being in youth victimization. Our primary aim was to use objective patient-reported quantitative measures to assess the change in health related quality of life (HRQOL) scores of youth who attended a violence intervention summer camp. This is the first study to evaluate such measures in youth victims of violence during an intervention. Methods: 8-18 year old youth who attended a violence intervention summer camp in a Midwest urban city over a two year period participated in a HRQOL survey at baseline and at the end of programming (6 weeks). Consented youth used an electronic platform to answer validated HRQOL measures. Mean differences in scores from baseline to 6 weeks were calculated and reported. Results: A total of 64 youth were recruited and consented to the study. Average change in scores improved in the majority of HRQOL domains with the largest change in scores seen in school functioning (mean diff: +5.00), emotional functioning (mean diff: +5.26), and patient anxiety (mean diff: +3.04). Only participant anger scored more poorly following the intervention (mean diff: -2.26). Conclusion: A community-based summer program hosting violently injured youth resulted in overall improved HRQOL. This was especially significant in the school, anxiety, and emotional domains. Future evaluation into the effectiveness of youth programs should measure HRQOL to identify at risk participants and to measure effectiveness. Level of Evidence: 3 (prognostic) (C) 2016 Lippincott Williams & Wilkins, Inc.
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Firefighter/EMT - City of Clermont Fire Department
CLERMONT, CITY OF 439 W HWY 50 CLERMONT, FLORIDA 34711 Updated: March 30, 2016 Classification: Firefighter/EMT The City of Clermont Fire Department is currently accepting applications for Firefighter/EMT. All testing through National Testing Network (NTN) must be completed by May 18, 2016. Salary Information: $13.78 to $21.08 per hour Benefit Information: Located within the job posting J ob Posting: ...
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New York City EMT for Event Medical Services at Iconic Venue - CrowdRx, Inc.
CrowdRx, Inc is the primary medical services provider for numerous iconic arenas, stadiums, and music festivals in the New York City metropolitan area. Are you an experienced Emergency Physician, Nurse, Paramedic, or Emergency Medical Technician with an unrestricted New York license" We’d love to meet you! Our comprehensive medical operations require professional and friendly staff who treat the ...
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Efficacy and toxicity of aerosolised colistin in ventilator-associated pneumonia: a prospective, randomised trial
Cases of ventilator-associated pneumonia (VAP) due to multidrug-resistant (MDR) gram-negative bacilli (GNB) mainly Acinetobacter baumannii, Pseudomonas aeruginosa and enterobacteria are common in hospitalised pat...
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Poor outcome is associated with less negative fluid balance in patients with aneurysmal subarachnoid hemorrhage treated with prophylactic vasopressor-induced hypertension
Aneurysmal subarachnoid hemorrhage (SAH) is a serious condition associated with high mortality rates and long-term disability. We investigated the impact of fluid balance on neurologic outcome after adjustment...
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Continuous venovenous hemofiltration decreases mortality and ameliorates acute lung injury in canine model of severe salt water drowning
Pulmonary edema is an important cause of complications and death in severe drowning. Continuous veno-venous hemofiltration (CVVH) may reduce pulmonary edema and thus may be a treatment modality for severe sea ...
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Geographic information system data from ambulances applied in the emergency department: effects on patient reception
Emergency departments (ED) recognize crowding and handover from prehospital to in-hospital settings to be major challenges. Prehospital Geographical Information Systems (GIS) may be a promising tool to address...
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Inside EMS Podcast: Is prehospital ultrasound the next big thing in EMS care?
Download this podcast on iTunes, SoundCloud or via RSS feed
In this Inside EMS Podcast episode, co-hosts Chris Cebollero and Kelly Grayson talk about the week's news, including a World War II veteran that was recently reunited with an ambulance he drove 71 years ago in Germany and a 5-year-old girl who saved her mother after the woman had a seizure while swimming in the family's pool.
At the guest table, Chris and Kelly talk to Dominick Walenczak, an Inside EMS podcast listener, paramedic from Buffalo, N.Y., and also a podcast host for Critmedic.com, about the many new diagnostic tools EMS providers are using aimed at prehospital care. Walenczak breaks down why more EMS providers should embrace the use of ultrasound in the field.
We want to know: do you think prehospital ultrasound is an expensive toy with no real clinical application" Or is it the next big thing in EMS care and diagnostics" Sound off in the comment section below.
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La. paramedic demonstrates importance of AEDs
Veteran paramedic Jason Hunt demonstrated the use in an effort to get a bill passed that would require high schools to have AEDs on campus
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Inside EMS Podcast: Is prehospital ultrasound the next big thing in EMS care?
Our co-hosts discuss the pros and cons of using ultrasound with a podcast listener
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Quick Clip: A listener's perspective on prehospital ultrasound
Paramedic Dominick Walenczak breaks down why more EMS providers should embrace the use of ultrasound in the field
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Seven-Year-Old Silver Spring Girl Hailed "Everyday Hero" For Saving's Dad's Life
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Seven-Year-Old Silver Spring Girl Hailed "Everyday Hero" For Saving's Dad's Life
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Seven-Year-Old Silver Spring Girl Hailed "Everyday Hero" For Saving's Dad's Life
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Clinical Interviewer: ALS Scenarios - Remote Medical International
About Us: At Remote Medical International® (RMI), we offer premium medical services to companies across a wide range of industries operating in remote or challenging locations in the US and abroad. Our global team of exceptional medical providers use their skills and expertise to implement leading health and safety initiatives, incorporate preventative health measures, oversee medical evacuations ...
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Seven-Year-Old Silver Spring Girl Hailed "Everyday Hero" For Saving's Dad's Life
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Association between alcohol intake and the risk of pancreatic cancer: a dose–response meta-analysis of cohort studies
BMC Cancer
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A comparison of midazolam, lorazepam, and diazepam for the treatment of status epilepticus in children: a network meta-analysis
Journal of Child Neurology
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Hey, Siri, I’m depressed
Stanford School of Medicine News
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Automated assessment of early hypoxic brain edema in non-enhanced CT predicts outcome in patients after cardiac arrest
Resuscitation
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Post-concussive syndrome after mild head trauma: epidemiological features in Tunisia
European Journal of Trauma and Emergency Surgery
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Attenuation of cardiovascular stress with sympatholytics does not improve survival in patients with severe isolated traumatic brain injury
The Journal of Trauma and Acute Care Surgery
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Prediction and detection models for acute kidney injury in hospitalized older adults
BMC Medical Informatics & Decision Making
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The association between a lifetime history of work-related low back injury and future low back pain: A population-based cohort study
European Spine Journal
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Examining Reliability and Validity of an Online Score (ALiEM AIR) for Rating Free Open Access Medical Education Resources
Annals of Emergency Medicine
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Aspirin as added prophylaxis for deep vein thrombosis in trauma: A retrospective case-control study
The Journal of Trauma and Acute Care Surgery
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Acute kidney injury
JAAPA
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Pilot study of a newly developed intervention for families facing serious injury
Topics in Spinal Cord Injury Rehabilitation
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Comparison of Macintosh, McCoy and C-MAC D-Blade video laryngoscope intubation by prehospital emergency health workers: a simulation study
Internal and Emergency Medicine
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Relation of contrast nephropathy to adverse events in pulmonary emboli patients diagnosed with contrast computerized tomography
The American Journal of Emergency Medicine
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Patient views on antimicrobial dressings in chronic wounds
British Journal of Nursing
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Influence of the temperature on the moment of awakening in patients treated with therapeutic hypothermia after cardiac arrest
Resuscitation
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Nontrauma open abdomens: A prospective observational study
The Journal of Trauma and Acute Care Surgery
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The role of acid-base imbalance in statin-induced myotoxicity
Translational Research, The Journal of Laboratory and Clinical Medicine
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Utility of procedural sedation as a marker for quality assurance in emergency medicine
The Journal of Emergency Medicine
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Early propranolol after traumatic brain injury is associated with lower mortality
The Journal of Trauma and Acute Care Surgery
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Intraluminal tranexamic acid inhibits intestinal sheddases and mitigates gut and lung injury and inflammation in a rodent model of hemorrhagic shock.
Background: Intravenous tranexamic acid (TXA) is an effective adjunct after hemorrhagic shock (HS) due to its antifibrinolytic properties. TXA is also a serine protease inhibitor and recent laboratory data demonstrated that intraluminal TXA into the small bowel inhibited digestive proteases and protected the gut. ADAM-17 and TNF[alpha] are effective sheddases of intestinal syndecan-1 which when shed, exposes the underlying intestinal epithelium to digestive proteases and subsequent systemic insult. We therefore hypothesized that intraluminal TXA as a serine protease inhibitor would reduce intestinal sheddases and syndecan-1 shedding, mitigating gut and distant organ (lung) damage. Methods: Mice underwent 90 minutes of hemorrhagic shock to a mean arterial pressure of 35+/-5 mm Hg following by the intraluminal administration of TXA or vehicle. After 3 hours, small intestine, lung, and blood were collected for analysis. Results: Intraluminal TXA significantly reduced gut and lung histopathologic injury and inflammation compared to hemorrhagic shock alone. Gut, lung, and systemic ADAM-17 and TNF[alpha] were significantly increased by hemorrhagic shock but lessened by TXA. Additionally, gut and lung syndecan-1 immunostaining were preserved and systemic shedding lessened after TXA. TXA reduced ADAM-17 and TNF[alpha], but not syndecan-1, in TXA-sham animals compared to sham vehicles. Conclusions: Results of the present study demonstrate a beneficial effect of intraluminal TXA in the gut and lung after experimental hemorrhagic shock in part due to inhibition of the syndecan-1 shedding by ADAM-17 and TNF[alpha]. Further studies are needed to determine if orally administered TXA could provide similar intestinal protection and thus be of potential benefit to patients with survivable hemorrhage at risk for organ injury. This is particularly relevant in patients or soldiers who may not have access to timely medical care. (C) 2016 Lippincott Williams & Wilkins, Inc.
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Inhibition of platelet function is common following even minor injury.
Background: Hemorrhage remains the leading cause of preventable death following injury. Whereas significant attention has been paid to the coagulation cascade, there are fewer studies evaluating platelet dysfunction following injury. Thrombelastogram platelet mapping (TEG-PM) allows for the measurement of maximal potential clot strength (MA) and clot strength selectively due to arachidonic acid (MA-AA) and adenosine disphosphate (MA-ADP) receptors on the platelet. The purpose of this study was to determine the incidence and magnitude of receptor-specific platelet dysfunction following injury in patients who are not otherwise pharmacologically anticoagulated. Methods: A retrospective study of adult trauma patients evaluated at a level I trauma center from August 2013-September 2014 was conducted. Platelet function was assessed using TEG-PM. Patients on any anticoagulant or antiplatelet medication were excluded. Patients were divided into those with and without radiographically evident brain injury (TBI). Demographic variables, injury severity (ISS), injury pattern, laboratory test results, and mortality were abstracted. Statistical comparisons were made using the student t-test or Mann-Whitney test. Results: The study includes 459 patients, 92% following blunt injury. MedianISS was 5. Patients with TBI (n=102) were significantly older (median age 54 v 35 years), more severely injured (median ISS 10 v 4), had a longer length of stay and higher mortality (9% v 0.3%). Maximal potential clot strength was normal in all cohorts but the arachidonic acid and adenosine diphosphate pathways were significantly inhibited (30+/-26% and 58+/-27%, respectively). There was no correlation between TEG-PM values and ISS, LOS, or mortality. There was no difference in the TBI cohort. There were no significant differences in TEG-PM parameters in those with an ISS greater than 14. There was no significant change in TEG-PM following platelet transfusion. Conclusion: Marked platelet inhibition is common following minor injury. Whereas the clinical significance of this finding remains unknown, the results of this study should be factored in the overall resuscitative strategy. Level of evidence: Level III Study type: Prognostic Study (C) 2016 Lippincott Williams & Wilkins, Inc.
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Early antithrombotic therapy is safe and effective in patients with blunt cerebrovascular injury and solid organ injury or traumatic brain injury.
Background: Early antithrombotic therapy (AT) is the mainstay of treatment in the management of blunt cerebrovascular injury (BCVI). In spite of this, optimal timing of initiation of AT in patients with BCVI in the presence of concomitant traumatic brain injury (TBI) or solid organ injury (SOI) remains controversial. The purpose of this study was to evaluate the impact of early initiation of AT on outcomes in patients with BCVI and TBI and/or SOI. Methods: Patients with BCVI and concomitant TBI and/or SOI over 6 years were identified. Aspirin and/or clopidogrel or low-intensity heparin infusion (AT) was instituted in all patients immediately upon diagnosis of BCVI. Cessation of AT, worsening TBI, need for delayed operative intervention, ischemic stroke, and mortality were reviewed and compared. Worsening of TBI or delayed operative intervention for SOI were compared to patients without BCVI treated at the same institution over the study period. Results: 119 patients (74 TBI, 26 SOI, and 19 combined) were identified. 71% were treated with heparin infusion (goal aPTT 45-60 seconds) and 29% received antiplatelet therapy alone. Compared to patients without BCVI, there was no difference in worsening of TBI (9% vs 10% with no BCVI, p=0.75) or need for delayed operative intervention for SOI (7% vs 5% with no BCVI, p=0.61). No patients required cessation of AT. A total of 11 (9%) of the patients experienced a BCVI-related stroke. Conclusions: Initiation of early AT for patients with BCVI and concomitant TBI or SOI does not increase risk of worsening TBI or SOI above baseline. Close monitoring is required, but our results suggest that appropriate antiplatelet or heparin therapy should not be withheld in patients with BCVI and concomitant TBI or SOI. In fact, prompt treatment with either antiplatelet or heparin therapy remains the mainstay for prevention of stroke-related morbidity and mortality in these patients. Level of Evidence: Therapuetic/Care Management, Level III (C) 2016 Lippincott Williams & Wilkins, Inc.
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Automated continuous vital signs predict use of uncrossed matched blood (UnXRBC) and massive transfusion (MT) following trauma.
Introduction: Recognizing the use of uncross-matched packed red blood cells (UnXRBC) or predicting need for massive transfusion (MT) in injured patients with hemorrhagic shock can be challenging. A validated predictive model could accelerate decision making regarding transfusion. Methods: Three transfusion outcomes were evaluated in adult trauma patients admitted to a level one trauma center over a four-year period (2009-2012): use of UnXRBC, use of >4 units of packed red blood cells (PRBC) within 4 hours (MT1) and use of >=10 units of PRBC within 24 hours (MT2). Vital Signs (VS) features including heart rate (HR), systolic blood pressure (SBP), and shock index (SI=HR/SBP) were calculated for 5, 10 and 15 minutes after admission. Five models were then constructed. Model 1 used preadmission VS, Model 2 used admission VS, Models 3, 4 and 5 used continuous VS features after admission over 5, 10 and 15 minutes, respectively to predict use of UnXRBC, MT1 and MT2. Models were evaluated for their predictive performance via area under the receiver operating characteristic curve (AUROC), positive predictive value (PPV), and negative predictive value (NPV). Results: Ten thousand six hundred and thirty six patients with over 5 million continuous VS data points during the first 15 minutes after admission were analyzed. Model using preadmission and admission VS had similar ability to predict UnXRBC, MT1 or MT2. Compared to these two models, predictive ability was significantly improved as duration of VS monitoring increased. Continuous VS for 5 minute had an ROC of 0.83 with confidence interval (CI) of 0.83-0.84, ROC of 0.85 (CI 0.84-0.86) and ROC of 0.86 (CI 0.85-0.88) to predict UnXRBC, MT1 and MT2, respectively. Similarly, continuous VS for 10 minutes had an ROC of 0.86 (CI 0.85-0.86), 0.87 (CI 0.86-0.88) and 0.88 (CI 0.87-0.90) to predict UnXRBC, MT1 and MT2, respectively. Continuous VS for 15 minutes achieved highest ROC of 0.87 (CI 0.87-0.88), 0.89 (CI 0.88-0.90) and 0.91 (CI 0.91-0.92) to predict UnXRBC, MT1 and MT2, respectively. Conclusion: Models using continuous VS collected after admission improve prediction for the use of UnXRBC or MT in patients with hemorrhagic shock. Decision models derived from automated continuous VS in comparison to single prehospital and admission VS identifies the use of emergency blood use and can direct earlier blood product administration, potentially saving lives. Level of Evidence: Level III (C) 2016 Lippincott Williams & Wilkins, Inc.
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Evaluation of Disseminated Intravascular Coagulation Scores in Critically Ill Pediatric Patients.
Objectives: Disseminated intravascular coagulation is a complex systemic thrombohemorrahgic disorder, which may contribute to organ failure. We aimed to compare the detection rate of the disseminated intravascular coagulation, early in the course of ICU admission, of the two disseminated intravascular coagulation scoring systems defined by International Society on Thrombosis and Hemostasis and Japanese Association for Acute Medicine criteria and the prognostic value of disseminated intravascular coagulation scores in critically ill pediatric patients. Design: Single-center retrospective observational study. Setting: PICU in a tertiary care children's hospital. Patients: Pediatric patients admitted in the PICU between January 2013 and December 2014. Interventions: None. Measurements and Main Results: A total of 191 patients were included. Among them, 15.7% and 29.8% of the patients were diagnosed with disseminated intravascular coagulation by International Society on Thrombosis and Hemostasis and Japanese Association for Acute Medicine criteria, respectively. The diagnostic concordance rate between the International Society on Thrombosis and Hemostasis and Japanese Association for Acute Medicine scoring systems was 52.6%. As the Pediatric Risk of Mortality III, the modified Sequential Organ Failure Assessment, and the Pediatric Multiple Organ Dysfunction Syndrome scores increased, the percentage of patients with disseminated intravascular coagulation increased stepwise. The disseminated intravascular coagulation scores correlated well with these severity scores. Overall, the 28-day mortality was 9.9%. There were significant differences in most variables consisting of the International Society on Thrombosis and Hemostasis and Japanese Association for Acute Medicine scoring systems between survivor and nonsurvivors. Patients detected to have disseminated intravascular coagulation by the International Society on Thrombosis and Hemostasis and Japanese Association for Acute Medicine scoring systems showed higher mortality than patients without disseminated intravascular coagulation. The areas under the receiver operating characteristic curve of the Japanese Association for Acute Medicine score and International Society on Thrombosis and Hemostasis score were 0.788 (95% CI, 0.675-0.900) and 0.716 (95% CI, 0.598-0.834), respectively. Conclusions: Both the International Society on Thrombosis and Hemostasis and the Japanese Association for Acute Medicine scoring systems are useful for detection of the disseminated intravascular coagulation in critically ill pediatric patients. These scores correlate well with other severity scores, including Pediatric Risk of Mortality III, modified Sequential Organ Failure Assessment, and Pediatric Multiple Organ Dysfunction Syndrome. Disseminated intravascular coagulation scores are also significantly associated with 28-day mortality, suggesting that these could be promising prognostic factors. (C)2016The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies
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Intracranial Hypertension and Cerebral Hypoperfusion in Children With Severe Traumatic Brain Injury: Thresholds and Burden in Accidental and Abusive Insults.
Objectives: The evidence to guide therapy in pediatric traumatic brain injury is lacking, including insight into the intracranial pressure/cerebral perfusion pressure thresholds in abusive head trauma. We examined intracranial pressure/cerebral perfusion pressure thresholds and indices of intracranial pressure and cerebral perfusion pressure burden in relationship with outcome in severe traumatic brain injury and in accidental and abusive head trauma cohorts. Design: A prospective observational study. Setting: PICU in a tertiary children's hospital. Patients: Children less than18 years old admitted to a PICU with severe traumatic brain injury and who had intracranial pressure monitoring. Interventions: None. Measurements and Main Results: A pediatric traumatic brain injury database was interrogated with 85 patients (18 abusive head trauma) enrolled. Hourly intracranial pressure and cerebral perfusion pressure (in mm Hg) were collated and compared with various thresholds. C-statistics for intracranial pressure and cerebral perfusion pressure data in the entire population were determined. Intracranial hypertension and cerebral hypoperfusion indices were formulated based on the number of hours with intracranial pressure more than 20 mm Hg and cerebral perfusion pressure less than 50 mm Hg, respectively. A secondary analysis was performed on accidental and abusive head trauma cohorts. All of these were compared with dichotomized 6-month Glasgow Outcome Scale scores. The models with the number of hours with intracranial pressure more than 20 mm Hg (C = 0.641; 95% CI, 0.523-0.762) and cerebral perfusion pressure less than 45 mm Hg (C = 0.702; 95% CI, 0.586-0.805) had the best fits to discriminate outcome. Two factors were independently associated with a poor outcome, the number of hours with intracranial pressure more than 20 mm Hg and abusive head trauma (odds ratio = 5.101; 95% CI, 1.571-16.563). As the number of hours with intracranial pressure more than 20 mm Hg increases by 1, the odds of a poor outcome increased by 4.6% (odds ratio = 1.046; 95% CI, 1.012-1.082). Thresholds did not differ between accidental versus abusive head trauma. The intracranial hypertension and cerebral hypoperfusion indices were both associated with outcomes. Conclusions: The duration of hours of intracranial pressure more than 20 mm Hg and cerebral perfusion pressure less than 45 mm Hg best discriminated poor outcome. As the number of hours with intracranial pressure more than 20 mm Hg increases by 1, the odds of a poor outcome increased by 4.6%. Although abusive head trauma was strongly associated with unfavorable outcome, intracranial pressure/cerebral perfusion pressure thresholds did not differ between accidental and abusive head trauma. (C)2016The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies
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Fluid Overload Is Associated With Late Poor Outcomes in Neonates Following Cardiac Surgery.
Objectives: Acute kidney injury is a severe complication of cardiac surgery associated with increased morbidity and mortality; yet, acute kidney injury classification for neonates remains challenging. We characterized patterns of postoperative fluid overload as a surrogate marker for acute kidney injury and as a risk factor of poor postoperative outcomes in neonates undergoing cardiac surgery. Design: Retrospective cohort study. Setting: Single, congenital heart center destination program. Patients: Four hundred thirty-five neonates undergoing cardiac surgery with cardiopulmonary bypass from January 2006 through December 2010. Interventions: None. Measurements and Main Results: Demographics, diagnosis, and perioperative clinical variables were collected, including daily weights and serum creatinine levels. A composite poor clinical outcome (death, need for renal replacement therapy or extracorporeal life support within 30 postoperative days) was considered the primary outcome measure. Twenty-one neonates (5%) had a composite poor outcome with 7 (2%) requiring renal replacement therapy, 8 (2%) requiring extracorporeal life support, and 14 (3%) dying between 3 and 30 days post surgery. Neonates with a composite poor outcome had significantly higher maximum fluid overload (> 20%) and were slower to diurese. A receiver-operating characteristic curve determined that fluid overload greater than or equal to 16% and serum creatinine greater than or equal to 0.9 on postoperative day 3 were the optimal cutoffs for significant discrimination on the primary outcome (area under the curve = 0.71 and 0.76, respectively). In multivariable analysis, fluid overload greater than or equal to 16% (adjusted odds ratio = 3.7) and serum creatinine adjusted odds ratio 0.9 (adjusted odds ratio = 6.6) on postoperative day 3 remained an independent risk factor for poor outcome. Fluid overload greater than or equal 16% was also significantly associated with cardiac arrest requiring cardiopulmonary resuscitation, prolonged ICU stay, and chest reexploration. Conclusions: This study highlights the importance of monitoring fluid balance in the neonatal cardiac surgical population and suggests that daily fluid overload, a readily available, noninvasive marker of renal function, may be a sensitive and specific predictor of adverse outcomes. (C)2016The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies
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Τετάρτη 30 Μαρτίου 2016
How to make community paramedicine work for your agency, Part I
The following is paid content sponsored by EMS Management & Consultants.
By EMS1 BrandFocus staff
Community paramedicine, also known as mobile integrated health, is catching on nationwide as a way to improve patient care while reducing costs. These programs are designed to better serve the community by redirecting the people using a disproportionate amount of emergency services to more appropriate, cost-effective providers.
Many of these so-called “frequent fliers” lack insurance and suffer from poor health literacy, chronic health problems, mental illness or addiction, and too often, these patients put a strain on EMS agencies even as they fall through the cracks. To determine whether a community paramedicine program is right for your agency and community, you must identify critical areas for improvement and gather data to support your argument.
Begin with a needs assessment
First, define the problem areas. What is the need? Are your agency’s resources stretched thin by a few frequent fliers? Is your local hospital looking to reduce readmissions? Are you getting a lot of calls for chronic, non-emergency issues?
A single frequent flier can put a lot of distress on a health care system. Anytime an ambulance is out of service, the capability of the system to treat the next patient is lower, plus the Medicare reimbursement rates for ambulance transport don’t cover the actual cost of an ambulance ride.
A patient who calls once a day or every other day becomes a significant stress on the system – but you can't refuse a call, because you never know when that incident may be critical. However, when a person continues to call for non-emergency issues, you can monitor the pattern and determine how to redirect that patient to appropriate care.
“A lot of patients call EMS because they're lonely, or they're calling because they're out of their meds, and if they get transported to the hospital they get their meds,” said Regina Godette-Crawford, advocacy liaison with EMS Management & Consultants. “We need to assess what the patient’s real issues are and stop the ambulance calls. Are they also tapped into social services? Are there behavioral issues? You’ll find out that there’s a common denominator in most.”
It’s important to identify these gaps in care and how EMS can help close them, working together with a variety of health care providers to find what’s best for your patients. This may require cooperation with local social services agencies to better understand the referral system, or with a hospital to define a set of frequently encountered conditions with repeated calls, high readmission rates and less-than-optimal outcomes. Look for opportunities to improve how you collaboratively care for those patients.
Generally, your target patients are both the most expensive and least likely to pay. In most cases, improved care also means reduced overall costs.
Gather data to demonstrate the need
You will need numbers to show that a problem exists so that you can make your case to policymakers. A good place to start is your patient care reports and billing data. Look for patterns. Are the majority of your calls non-emergency concerns? Is there a clearly identifiable set of high-frequency patients that every medic in your system knows by name?
Look beyond your response times and survival rates for local patterns and gaps in care. Tracking how frequently your agency makes referrals to social service agencies is another useful metric. Measuring these referrals will enable you to report these patterns to policymakers and show the need for interventions that can make a lasting difference in patients’ lives and ease the strain on the system by directing them to more appropriate providers.
“There really is more bang for your buck in doing what's best for the patient,” said Godette-Crawford, “but you've got to be able to sell that, and the only way that you can sell that is to show data.”
Making the case for a community paramedicine program
In order to gain support for a community paramedicine program, you’ll need to communicate three things to policymakers: how the current system is not meeting the community’s health care needs, the adverse effects these problems have on your agency and the overall system, and how your proposed solution will help close the gap.
Be prepared to share and explain the data you’ve collected. You’ll also need these numbers to measure cost savings and improved patient outcomes to gauge the success of your program once it’s launched.
Once you’ve gathered your data to demonstrate the need for a new solution, it can be helpful to use an evaluation tool like the one from the federal Health Resources and Services Administration (HRSA) to help you assess your community’s needs and your agency’s strengths. Many states require agencies to complete the HRSA assessment before launching a program, and whether required or not, using a widely respected set of criteria will help you make your case.
Identify community partners and begin conversations
Community paramedicine is, by definition, a collaborative effort. Your needs assessment will tell you who should be involved in the planning discussions. Meet with representatives from the health care organizations that are most likely to play a part. Generally, this will include public health and social services agencies, but you may also want to bring private hospitals, home health agencies and other practitioners to the table, depending on who else is involved in treating your target population.
Some agencies may compete. For example, home health nurses may balk at the idea of paramedics making home visits that provide similar services. Others, like hospitals looking to reduce readmissions for a particular condition, may provide limited funding for a pilot program to establish cost savings. It’s important to bring these stakeholders to the table to establish the scope of your program, set goals and build consensus.
“Building a coalition and marketing it to build community engagement is critical,” said Godette-Crawford, an advocate for community paramedicine programs and other EMS issues in North Carolina. “You’re going to have a very fragmented system if you don’t partner together, and the whole point is coming together to have a unified approach to this that would benefit everybody.”
Is community paramedicine the right strategy for your agency?
There is no blueprint for success, but a comprehensive community paramedicine program must be built on a careful assessment of the health needs of your community and strategic partnerships with a spectrum of health care providers. Read Part II of this article, coming in May, to learn more about key steps to launching a community paramedicine program.
For more information about community paramedicine and other EMS issues, contact EMS Management & Consultants.
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When overdoses go wild: Protecting the EMS provider
EMS providers face a variety of hazards while on the job. About 10 percent of all EMS provider injuries are a result of some form of violence [1]. An unknown percentage of these violent acts involve patients who have abused some form of drug or medication, and present in an altered state. This article explores violent patient behavior associated with substance abuse, as well as how to anticipate and manage these situations as to minimize their danger.
Epidemiology of patient violence
While there is are no definitive statistics specific to the incidence of substance abuse-related violence against EMS providers, a 2002 study that looked at the nature of prehospital violent behavior concluded that the perceived presence of alcohol and drug use was predictive of violent behavior, along with police presence, the presence of gang members and perceived psychiatric disorder [2].
Chemistry of emotion and behavior
How humans create, experience and regulate emotion is not well understood. Chemical neurotransmitters such as dopamine, serotonin, and GABA are known to be involved in feelings such as being happy or being sad.
How we react to certain situations is rooted within the body's autonomic nervous system. Two branches, the sympathetic and parasympathetic systems work in conjunction in each other, regulating most bodily functions on a minute-to-minute basis.
The sympathetic system is the source of the well-described "flight or fight" reflex, where the body is programmed to react to sudden stress by increasing heart rate, contractility, and respiratory rate. Blood is shunted away from the skin and GI tract and toward the heart, lung, kidneys and the broad muscle beds. The brain experiences fear, stress and anxiety. Altogether, this response to a stressor serves the body well in protecting it from harm. But this same response may be triggered by the effects of substance abuse and overdose, creating a potentially dangerous situation for patients and EMS providers alike.
Specific drugs related to violence
There are a wide variety of drugs that can be used recreationally and sometimes, illicitly to solicit a sense of pleasure and euphoria. A subset of drugs have been associated with aggressive or violent behavior. Additionally, prescription medications designed specifically to manage various psychiatric conditions have known to trigger acts of verbal and/or physical aggression, sometimes unexpectedly. Here are the drugs EMS providers commonly encounter.
Ethanol
Ethyl alcohol, or ethanol is the intoxicating ingredient in beer, wine and spirits. Ethanol is a central nervous system depressant, raising levels of GABA neurotransmitters that first cause a euphoric effect, followed by a general slowing of bodily functions. Excessive amounts will cause both cognitive and physical dysfunction.
Alcohol is considered to be the most common drug associated with violence. People can become angry and aggressive while under the influence of ethanol. Being verbally or physically abused by another person is twice as likely to occur if ethanol is involved [3].
What makes ethanol-driven violence more unpredictable is that there is no dose-effect relationship. It is unclear why ethanol can make one person feel happy and sleepy, but cause another person to be hostile and violent.
Ethanol is also commonly used in conjunction with other drugs. It can have an additive effect, especially with other GABA related drugs such as benzodiazepines (diazepam and midazolam, for example.)
Stimulants
As the name indicates, this general classification of drugs stimulates the central nervous system, specifically the sympathetic portion. A common subclass of stimulants is amphetamines. Drugs such Adderall (dextroamphetamine), used to treat attention deficit disorder, belong to this category, as well as illicit drugs like methamphetamine.
An emerging stimulant, alpha-PVP is a strong stimulant with highly addictive properties. It belongs in the same classification as "bath salts." People who have used alpha-PVP, also known as Flakka, have been known to be very physically violent, paranoid and difficult to control. The behavior is reminiscent of the older drug phenycycline, or PCP.
Antipsychotics
There is a wide regiment of prescription medications that are used to treat a variety of psychiatric conditions. Several have been linked to high incidences of aggressive or violent behavior [4]. The five most common medications in this category are listed in the following table.
Drug name
Trade Name
Used to treat
Fluoxetine
Prozac
Depression, obsessive-compulsive disorder
Paroxetine
Paxil
Depression, obsessive-compulsive disorder, anxiety
Fluvoxamine
Luvox
Obsessive-compulsive disorder
Venlafaxine
Effexor
Anxiety disorders
Desvenlafaxine
Pristiq
Anxiety disorders
Anti-smoking medication
Varenicline (Chantix) is an anti-smoking medication that works to reduce nicotine cravings by affecting the nicotinic acetylcholine receptor sites in the brain. It is 18 times more likely to be linked with violent behavior when compared to other medications [4].
Anti-malaria medication
Mefoquine (Lariam) is used to treat malaria, and has been long associated with increased violent behavior.
Anabolic steroids
Anabolic–androgenic steroids are synthetic forms of testosterone, the male sex hormone. Anabolic steroids are used by some athletes to improve physical performance. High doses of anabolic steroids have been linked to greater irritability and aggression, although the relationship is highly variable.
Cannabis withdrawal
Several studies have found a possible relationship between marijuana use and interpersonal violence [5], especially in teenagers [6]. However, there is no clear link established. People who are withdrawing from marijuana use have reported greater irritability which can lead to aggressive behavior in people with a previously known history of aggression [7].
General safety practice guidelines
EMS providers are responsible for the safety of their patients, as well as the care they receive in the field setting. The potential for violence when a patient is under the influence of a drug or medication increases the chances of danger to the caregiver. Under extreme circumstances where the rescuer's life is in danger, the patient ceases to be a patient and should be considered an assailant. Retreating from the scene in these circumstances and waiting for law enforcement assistance is appropriate.
However in most circumstances EMS and other public safety providers must quickly develop a plan to safely manage a potentially violent patient. Maintaining a heightened sense of situational awareness by all rescuers can keep the scene in control and anticipate sudden changes in the patient's behavior. The EMS provider rendering direct patient care should be covered by another member of team who can quickly assist if the patient's behavior changes during the assessment and management phase.
Consider the possibility of sudden violence if the patient is exhibiting one or more of these behaviors:
- Sudden erratic movements
- Tightening of facial muscles, arms, hands into fists
- Darting eye movement
- Fixed stare
- Shifting balance into an aggressive posture
- Raised voice, rapid speech
- Rapid breathing
The initial management approach is to stay calm and listen. Allow the patient to vent while sizing up the situation for potential weapons and escape routes. Actively engage with the patient's conversation; acknowledge what the patient is saying or feeling while not injecting your own opinion into the discussion. Affirm the patient's statements ("I hear you saying…."); this may help the patient calm down some and establish a working relationship or rapport with you.
Avoid trapping patients into situations where they feel they have no options. Give options whenever possible. An example might be the choice of walking to the unit or being wheeled on the gurney. The choices should be realistic; someone with altered mental status would not have the option of refusing care.
If verbal defusing techniques are not effective, a plan must be rapidly developed to restrain the patient physically, chemically or both. No fewer than five rescuers are needed to safely restrain a patient. The team must quickly decide who will gain the patient's attention while the other embers surround the patient. Control is taken in one simultaneous motion and soft restraints applied.
Patients must be restrained in a supine position. Chemical restraint with benzodiazepines or haloperidol have been demonstrated to be safe and effective. If you suspect excited delirium consider ketamine for patient sedation.
Most importantly, EMS providers must remain in control of their own emotions in these highly stressful situations. Remaining calm reduces the chances of escalating an already bad situation into a disastrous one.
References
1. Centers for Disease Control and Prevention. Emergency Medical Services Workers: Injury and Illness Data. http://ift.tt/1q3uzqj. Retrieved 10 January 2016.
2. Grange J and Corbett SW. Violence against emergency medical services personnel. Pre Emerg Care 6(2): 186-90. 2002.
3. Morgan A, McAtamney A. Key issues in alcohol-related violence. Australian Institute of Criminology, December 2009.
4. Moore TJ, Glenmullen J, Furberg CD. Prescription Drugs Associated with Reports of Violence Towards Others. PLoS ONE 5(12): e15337. December 2010. http://ift.tt/1OMzP80"id=10.1371/journal.pone.0015337 retrieved 12 January 2016.
5. Moore TM, Stuart GL. A review of the literature on marijuana and interpersonal violence. Aggression and Violent Behavior 2005;10:171-192.
6. Copeland J, Rooke S, Swift W. Changes in cannabis use among young people: impact on mental health. Current Opinion in Psychiatry 2013;26(4):325-329.
7. Smith PH, Homish GG, Leonard KE, Collins RL. Marijuana withdrawal and aggression among a representative sample of U.S. marijuana users. Drug Alcohol Depend. 2013 Sep 1;132(1-2):63-8.
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When overdoses go wild: Protecting the EMS provider
Learn how to anticipate, recognize, and manage violent patient encounters to minimize danger to yourself and the patient
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SAE Standards for ambulance safety
Recommendations from SAE describe specific testing standards to minimize the risk of injury to providers and patients during an ambulance collision
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Safety, efficacy and clinical generalization of the STAR protocol: a retrospective analysis
The changes in metabolic pathways and metabolites due to critical illness result in a highly complex and dynamic metabolic state, making safe, effective management of hyperglycemia and hypoglycemia difficult. ...
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SAE Standards for ambulance safety
In 2014, the Society of Automotive Engineers released a set of four updated recommendations regarding safety standards for ambulances. The SAE is a professional organization that primarily develops "best practices" for the automotive, aerospace, and commercial vehicle industries. The four new recommendations join two existing sets of standards, and cover patient compartment restraint, litter integrity, equipment mounting systems, and both front- and side-impact safety systems.
The guidelines for ambulance safety were developed in conjunction with NIOSH and the Ambulance Manufacturers Division of the National Truck Equipment Association. Although a U.S. based group, the SAE recommendations are meant to be used globally in the development and production of ambulances and equipment.
Who determines ambulance design specifications"
The process of regulating ambulance safety varies significantly state by state. In the United States, the federal government outlines a set of specifications in a General Service Administration document called the KKK-A1822 (often referred to as "the Triple-K"). This set of specifications, developed in 1976, has gone through several updates, most of which were influenced by the evolving SAE recommendations [1].
In addition to the Triple-K, the National Fire Protection Association has also published its own ambulance design standards, called NFPA 1917. Like the Triple-K, NFPA 1917 incorporates many of the SAE recommendations for crash safety.
Finally, the Commission on Accreditation of Ambulance Services (CAAS) has a separate set of standards called GVS v1.0 that, like the Triple-K and the NFPA, is based on the SAE safety recommendations.
Although these three documents vary slightly in scope, they all set forth a number of best practices regarding ambulance design that agree with many of the current SAE recommendations. However, the adoption of any standard at all is not federally mandated.
Currently, 30 states use all or part of the Triple-K in their ambulance safety standards. Six states have no legislated ambulance design regulations at all, and the remaining states have regulations that may or may not include Triple-K or SAE specifications [2].
Although the Triple-K standards appear to be the most widely used, they are set to expire in October 2016, leaving the NFPA and CAAS standards in relative competition for adoption as the industry standard in EMS [3]. EMS leaders should research what standards, if any, are mandated in the state in which they operate.
Although state regulations play a major role in the adoption and implementation of any ambulance safety standards, other factors come into play. For example, any agency that receives equipment funding through the Assistance to Firefighters Grant is required, through the terms of the grant, to comply with published SAE standards regardless of any state regulations [4].
Individual equipment manufacturers, in an effort to be competitive and at the top of the market, design and sell products that meet many, if not all, of the SAE standards. Because of this, states without any regulation at all may still meet some or all of the suggested safety standards simply by nature of the equipment used in the ambulances operating within the state.
The actual SAE recommendations
The bulk of the SAE recommendations describe specific testing standards to be used by equipment manufacturers to ensure the safety of patients and providers during ambulance operations. These tests strongly resemble those used by civilian auto manufacturers. In fact, a main point of the 2014 SAE recommendations is to provide patient compartment occupants with the same level of crash protection as passenger vehicles.
These standards include impact testing utilizing crash-test manikins positioned in front, side and rear facing ambulance seats, as well as secured to a gurney using the recommended combination of lap and shoulder belts. The SAE outlines both static and dynamic testing procedures with the goal of providing manufacturers with clear standards for evaluating the safety of their products. The recommended testing also includes equipment restraint systems, and systems used to secure the gurney in the patient compartment.
Traditionally, patient cots were secured in the patient compartment with a standard antler and rail system that stabilizes the head of the cot with floor-mounted metal antlers, and locks the foot of the cot into a side mounted rail. Patients are typically secured to the cot using a combination of lap and shoulder belts designed, in theory, to prevent forward movement of the patient during a collision.
A NIOSH study conducted during the development of the SAE standards showed that during a front-impact collision at a speed of 30 mph, the antler and rail system allowed for approximately 30 inches of forward movement of the patient cot and patient. The force of a front impact at 30 mph was significant enough to cause the gurney to break free of the antlers, sending a restrained patient forward into the space often occupied by the captain's chair or jump seat in the patient compartment [5].
The 2014 SAE standard J3027 requires that the patient cot be configured in such a fashion that forward movement of the cot and patient during a front-end collision is limited to 14 inches, rather than the previous 30 inches [6]. In July of 2015, the GSA adopted Change Notice 8, which added this requirement for cot and patient security (SAE J3027) into the KKK standard. This means that traditional antler and rail systems will no longer be compliant, should states adopt this aspect of the KKK standard.
The additional SAE standards also cover equipment-mounting systems and provide requirements for interior surface delethalization, making impact surfaces less likely to injure the patient or health care provider in the event of a collision. Equipment mounting systems in SAE compliant ambulances would need to show stability of standard equipment like oxygen cylinders and cardiac monitors during front, side, and rollover collision conditions.
Surface delethalization also involves replacing current hard impact surfaces with padded materials, or materials that collapse upon significant impact, in order to reduce injuries to providers during collisions.
Research and development continues in the area of provider restraint in the patient compartment. Identifying and implementing an effective provider restraint system is a challenging task, as the restraint must simultaneously allow movement during patient care while providing security in the event of a collision.
A variety of provider restraint systems exist, from bench seats that slide and swivel to retractable harness restraints that allow full movement around the patient compartment. While the SAE does not currently specify a specific restraint system, it does provide recommendations for the maximum allowable movement of a restrained provider in the patient compartment during an ambulance collision.
Another interesting inclusion in the SAE standards is an evaluation of provider body size and shape. The NIOSH EMS Anthropometry Study evaluated 680 human subjects in an attempt to identify common body sizes and shapes so that ergonomically efficient standards could be developed for ambulance construction and restraint systems [7].
This project is set to end in 2016, and will likely affect ongoing updates to the SAE standards. It is worth noting that the Triple-K, NFPA, and CAAS standards are all based on a provider weight of between 171 and 175 pounds, which may not accurately reflect the average provider size [3].
Improve safety habits
It is widely recognized that ambulance crashes are a significant problem. Between 1992 and 2011, an estimated 4,500 vehicle crashes involving an ambulance occurred each year. Of those, 34 percent involved injuries, and an average of 29 fatal crashes occurred each year [8].
The 2014 SAE standards, if adopted, will take years to fully implement as existing apparatus and equipment are replaced with new, compliant products. Until such time as ambulances become compliant with the new standards, providers should continue to practice safe habits when driving or working in an ambulance.
During patient care and transport, providers should be restrained by lap-shoulder belts when in front and rear facing seats, and lap belts when in side facing seats. Any additional restraint systems installed in an individual ambulance, such as five point harnesses, should be utilized whenever possible.
Patients should be secured to the patient cot with all available straps. Providers should be familiar with the manufacturer recommendations regarding proper fit of patient cot straps or seatbelts to ensure the patient is as protected as well as possible in the event of a collision.
Given the propensity of antler-rail mounted gurneys to move significantly forward during a collision, providers should avoid sitting directly behind the head of the patient cot whenever possible.
Heavy bags and equipment should be routinely secured during ambulance operations. Oxygen cylinders, cardiac monitors, and larger suction units should all be firmly stabilized to prevent movement during a collision or rollover. Loose equipment unsecured in the patient compartment, even small items, should be avoided. Cabinets and bins should either be securely closed or the items inside them otherwise confined to the inside of the cabinet space.
Finally, there is no substitute for careful, aware, defensive driving when it comes to maximizing the safety of patients and providers, as well as the drivers and occupants of other vehicles. An Emergency Vehicle Operation Course provides necessary training in safe ambulance driving.
It is critical to avoid distractions while driving such as eating, drinking, radio usage, GPS navigation and smartphone communication. Communication between the driver and the provider in the patient compartment regarding bumps, sharp turns, and other road conditions is of high importance.
It remains the individual responsibility of each provider to always use seatbelts and restraints in the manner in which they were intended, to minimize the potential for injury in the event of a collision. As with any other aspect of EMS work, personal safety for the provider must be the first priority during ambulance operations.
References:
1. Vogt F (1976). "Equipment: Federal Specification, Ambulance KKK-A-1822". Emerg Med Serv 5 (3): 58, 60–4. PMID 1028572.
2. "Executive Summary, Understanding the SAE Conversation." Executive Summary. Ferno. Web. 13 Mar. 2016.
3. "AEV Briefing on Current Status of Ambulance Standards Projects." NAEMT.org. Web. 13 Mar. 2016.
4. "Assistance Firefighter Grant." Fema.gov. Web. 13 Mar. 2016.
5. Castillo, Dawn, Thomas Bobick, and Stephanie Pratt. "New Research and Findings from the NIOSH Division of Safety Research." ASSE Professional Development Conference and Exposition. American Society of Safety Engineers, 2013.
6. "Ambulance Patient Compartment Seating Integrity and Occupant Restraint." J3026. Web. 13 Mar. 2016.
7. "EMERGENCY MEDICAL SERVICES WORKERS." Centers for Disease Control and Prevention. Centers for Disease Control and Prevention, 2014. Web. 13 Mar. 2016.
8. "NHTSA Traffic Safety Facts 2011." National Highway Traffic Safety Administration. NHTSA.gov. Web. 13 Mar. 2016
9. "About SAE International." SAE Mission and Vision Statements. Web. 15 Mar. 2016.
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Analysis of death in major trauma: value of prompt post mortem computed tomography (pmCT) in comparison to office hour autopsy
To analyze diagnostic accuracy of prompt post mortem Computed Tomography (pmCT) in determining causes of death in patients who died during trauma room management and to compare the results to gold standard aut...
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EMS Educator - Mineral Area College
Teach from the following list of courses: Emergency Medical Responder (EMR), Emergency Medical Technician (EMT), Anatomy & Physiology for Pre-hospital Professionals, Principles of Paramedic Technology, Pharmacology for Paramedics, Paramedic Clinical, Laboratory/Practicum, EMS Internships, continuing education and other courses as needed; evaluate and revise course materials; advise students; participate ...
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EMT - Safety Technician - On-Site Health & Safety
Have you enjoyed working as an EMT...but wish your role involved more skills, better wages, and a viable opportunity for career growth" We're On-Site Health & Safety...an established, twenty-year, multi-state Health & Safety Company, looking for qualified candidates to join our growing team across the country in challenging, non-traditional injury management settings. OSHS Health & Safety ...
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Fort Smith EMS Medic - Fort Smith EMS
Paramedic working 12 hour shifts, 3 days week 1, 4 days week 2, 84 hour schedule. Providing emergent care for the citizens of Fort Smith.
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Quality Improvement Analyst, 911 - Allina Health
*Responsibilities Identify patient care opportunities for improvement. Develop tracking tools and measures for improvement and report to AHEMS Leadership on regular basis. Assist in determining the parameters needed to be measured for AHEMS care goals Audit and abstract patient care records to identify trends and to measure progress and improvement opportunities Work with physicians and managers to ...
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After four decades, a Texas EMT is still eager to answer calls
In 1990, EMT Richard Ponikiewski already had 13 years in EMS, and was about to answer the most difficult call of his career.
"It was around 2 a.m.," the 57-year-old Irving, Texas native recalls. "We were sent to an apartment complex for an unresponsive four-year-old. The mother had just gotten home and called 9-1-1 when she wasn’t able to wake up her son.
"When we got to the scene, a firefighter came running through the house with the child in his arms. That little boy was in bad, bad shape.
"The mother’s boyfriend had been watching the kid and his two-year-old brother. They’d been taking a bath and had splashed some water on the floor. When the boyfriend saw that, he beat the older boy unconscious for not knowing better.
"I wish I could tell you what we did en route, or what happened when we got to the hospital, but I don’t remember any of it. All I can say is the boy died."
But there’s more to the story. The boundary between our jobs and personal lives isn’t always as well-defined as we think.
"After the call, I was sitting on the bumper of the truck at the hospital waiting for my partner to finish up. He came out of the ER and asked me if was okay. I said, 'Yeah, why?' Then he said, 'Do you know why we’re here?' I couldn’t remember. I still can’t recall anything that happened from the time we left the scene until we walked out of the ER."
Ponikiewski’s patient had been the same age as his son, Dustin, with almost identical blonde hair and blue eyes. To Richard, the two boys had been one.
"I came to understand that I’d blocked out most of the memories of that call because it was just so horrible to see someone like my son lying there, all beat up.
"Whenever I do peds now, I look at them and think how helpless they are; how much they depend on their parents. Then I see mom and dad and wonder what they’ve been doing to care for their kids. I mean, why shouldn’t a child with a fever get Tylenol? Almost 99 percent of the time, they don’t."
Ponikiewski knows it isn’t his place to lecture parents about childcare. "The customer is always right – isn’t that the way it’s supposed to be? Besides, my folks always taught me not to say anything I’d regret later."
EMS is where you find it
Discretion wasn’t the only EMS-applicable advice Ponikiewski got as a youngster. In high school, after injuries interfered with his efforts to play both football and baseball, one of the athletic trainers introduced him to emergent care.
"He showed me not only how to treat injuries, but how to help prevent them, by taping ankles and things like that," Ponikiewski says. "I started to think, ‘Hey, this isn’t a bad gig.’
"The trainer tried to get me into a local college where I could learn to do his job. I didn’t get accepted, but I figured I could still find a way to do something medical."
Right after graduation in 1977, Ponikiewski got certified as an Emergency Care Attendant and went to work for Dallas-based American Ambulance.
"They were a mom-and-pop service with three or four trucks that did mostly transfers and stand-bys," the 39-year EMS veteran says. "I was their jack-of-all trades. Sometimes I’d be in the field and sometimes I’d dispatch. If they needed a spot filled, I’d do it."
Shortly after he became an EMT in 1978, Ponikiewski had two memorable calls.
"The first one was a routine transport from a nursing home to the hospital," he says. "The patient was the proverbial little old lady in her ‘90s, all contracted.
"I was assessing her on the way when she stopped breathing. There was no pulse, so I started CPR.
"At the hospital, everyone was working on her, trying to get IVs and get her intubated, when this doctor comes over and says, 'Why are you doing CPR on a dead lady? She’s stiff, leave her alone.' He didn’t believe she’d been breathing just a few minutes earlier. That really made me feel bad.
"The other call was an elderly female we were transporting by airplane to her home in Tennessee, where she could die with dignity.
"About halfway there, the pilot asked, 'Do you smell that?' I thought he was joking until I got a whiff of gasoline.
'That’s our fuel,' he said. 'We have a leak. We need to find an airport.'
"We landed pretty quickly in Hope, Arkansas, which happens to be the birthplace of Bill Clinton. It was a Sunday, so it took a little while to find a mechanic. We carried the patient into the local FBO (fixed-base operator) and waited about three hours while they fixed the fuel line. We eventually got to Winchester, Tennessee without any other trouble."
Moving on from mom-and-pop
When another agency took over American Ambulance’s district in 1986, Richard went to work for MedStar Mobile Healthcare, serving a population of 800,000 in Fort Worth and 13 neighboring cities. He’s been there ever since.
From 1993 until 2013, Ponikiewski partnered with Ronnie Ferguson, a paramedic who became a good friend and mentor.
"We got to do something you hardly ever hear about in EMS," says Ponikiewski. "We delivered the daughter and granddaughter of one of our patients.
"Ronnie was always trying to get me to better myself; to become a medic like him. He’d quiz me on calls: What should we do next? Why?
"Unfortunately, Ronnie died of colon cancer in 2013. I try to pass along to students some of what he used to say to me: Don’t be so gung-ho about doing everything at once. Start with the basics. Understand what’s going on before you start pushing drugs."
Sounds like Ronnie would be proud.
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Near-infrared spectroscopy monitoring during cardiac arrest: a systematic review and meta-analysis
Abstract
Background
Tissue oximetry using near-infrared spectroscopy (NIRS) is a non-invasive monitor of cerebral oxygenation. This new technology has been used during cardiac arrest (CA) because of its ability to give measures in low blood flow situations. The aim of this study was to assess the evidence regarding the association between the types of NIRS measurements (mean, initial and highest values) and resuscitation outcomes (return of spontaneous circulation (ROSC), survival to discharge and good neurologic outcome) in patients undergoing cardiopulmonary resuscitation.
Methods and results
This review was registered (Prospero CRD42015017380) and is reported as per the PRISMA guidelines.
Medline, Embase and CENTRAL were searched. All studies, except case reports and case series of fewer than five patients, reporting on adults that had NIRS monitoring during CA were eligible for inclusion. Two reviewers assessed the quality of the included articles and extracted the data. The outcome effect was standardized using standardized mean difference (SMD).
Twenty non-randomized observational studies (15 articles and five conference abstracts) were included in this review, for a total of 2436 patients. We found a stronger association between ROSC and mean NIRS values (SMD 1.33 [95% confidence interval (CI) 0.92-1.74]) than between ROSC and initial NIRS measurements (SMD 0.51 [95% CI 0.23-0.78]). There was too much heterogeneity amongst the highest NIRS measurements group to perform meta-analysis. Only two of the 75 patients who experienced ROSC had a mean NIRS saturation under 30%. Patients who survived to discharge and who had good neurologic outcome displayed superior combined initial and mean NIRS values than their counterparts (SMD 1.63 [95% CI 1.34-1.92]; SMD 2.12 [95% CI 1.14-3.10]).
Conclusions
Patients with good resuscitation outcomes have significantly higher NIRS saturations during resuscitation than their counterparts. The types of NIRS measurements during resuscitation influenced the association between ROSC and NIRS saturation. Prolonged failure to obtain a NIRS saturation higher than 30% may be included in a multi-modal approach to the decision of terminating resuscitation efforts (Class IIb, Level of Evidence C-Limited Data).
This article is protected by copyright. All rights reserved.
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After four decades, a Texas EMT is still eager to answer calls
In 1990, EMT Richard Ponikiewski already had 13 years in EMS, and was about to answer the most difficult call of his career.
"It was around 2 a.m.," the 57-year-old Irving, Texas native recalls. "We were sent to an apartment complex for an unresponsive four-year-old. The mother had just gotten home and called 9-1-1 when she wasn’t able to wake up her son.
"When we got to the scene, a firefighter came running through the house with the child in his arms. That little boy was in bad, bad shape.
"The mother’s boyfriend had been watching the kid and his two-year-old brother. They’d been taking a bath and had splashed some water on the floor. When the boyfriend saw that, he beat the older boy unconscious for not knowing better.
"I wish I could tell you what we did en route, or what happened when we got to the hospital, but I don’t remember any of it. All I can say is the boy died."
But there’s more to the story. The boundary between our jobs and personal lives isn’t always as well-defined as we think.
"After the call, I was sitting on the bumper of the truck at the hospital waiting for my partner to finish up. He came out of the ER and asked me if was okay. I said, 'Yeah, why"' Then he said, 'Do you know why we’re here"' I couldn’t remember. I still can’t recall anything that happened from the time we left the scene until we walked out of the ER."
Ponikiewski’s patient had been the same age as his son, Dustin, with almost identical blonde hair and blue eyes. To Richard, the two boys had been one.
"I came to understand that I’d blocked out most of the memories of that call because it was just so horrible to see someone like my son lying there, all beat up.
"Whenever I do peds now, I look at them and think how helpless they are; how much they depend on their parents. Then I see mom and dad and wonder what they’ve been doing to care for their kids. I mean, why shouldn’t a child with a fever get Tylenol" Almost 99 percent of the time, they don’t."
Ponikiewski knows it isn’t his place to lecture parents about childcare. "The customer is always right – isn’t that the way it’s supposed to be" Besides, my folks always taught me not to say anything I’d regret later."
EMS is where you find it
Discretion wasn’t the only EMS-applicable advice Ponikiewski got as a youngster. In high school, after injuries interfered with his efforts to play both football and baseball, one of the athletic trainers introduced him to emergent care.
"He showed me not only how to treat injuries, but how to help prevent them, by taping ankles and things like that," Ponikiewski says. "I started to think, ‘Hey, this isn’t a bad gig.’
"The trainer tried to get me into a local college where I could learn to do his job. I didn’t get accepted, but I figured I could still find a way to do something medical."
Right after graduation in 1977, Ponikiewski got certified as an Emergency Care Attendant and went to work for Dallas-based American Ambulance.
"They were a mom-and-pop service with three or four trucks that did mostly transfers and stand-bys," the 39-year EMS veteran says. "I was their jack-of-all trades. Sometimes I’d be in the field and sometimes I’d dispatch. If they needed a spot filled, I’d do it."
Shortly after he became an EMT in 1978, Ponikiewski had two memorable calls.
"The first one was a routine transport from a nursing home to the hospital," he says. "The patient was the proverbial little old lady in her ‘90s, all contracted.
"I was assessing her on the way when she stopped breathing. There was no pulse, so I started CPR.
"At the hospital, everyone was working on her, trying to get IVs and get her intubated, when this doctor comes over and says, 'Why are you doing CPR on a dead lady" She’s stiff, leave her alone.' He didn’t believe she’d been breathing just a few minutes earlier. That really made me feel bad.
"The other call was an elderly female we were transporting by airplane to her home in Tennessee, where she could die with dignity.
"About halfway there, the pilot asked, 'Do you smell that"' I thought he was joking until I got a whiff of gasoline.
'That’s our fuel,' he said. 'We have a leak. We need to find an airport.'
"We landed pretty quickly in Hope, Arkansas, which happens to be the birthplace of Bill Clinton. It was a Sunday, so it took a little while to find a mechanic. We carried the patient into the local FBO (fixed-base operator) and waited about three hours while they fixed the fuel line. We eventually got to Winchester, Tennessee without any other trouble."
Moving on from mom and pop
When another agency took over American Ambulance’s district in 1986, Richard went to work for MedStar Mobile Healthcare, serving a population of 800,000 in Fort Worth and 13 neighboring cities. He’s been there ever since.
From 1993 until 2013, Ponikiewski partnered with Ronnie Ferguson, a paramedic who became a good friend and mentor.
"We got to do something you hardly ever hear about in EMS," says Ponikiewski. "We delivered the daughter and granddaughter of one of our patients.
"Ronnie was always trying to get me to better myself; to become a medic like him. He’d quiz me on calls: What should we do next" Why"
"Unfortunately, Ronnie died of colon cancer in 2013. I try to pass along to students some of what he used to say to me: Don’t be so gung-ho about doing everything at once. Start with the basics. Understand what’s going on before you start pushing drugs."
Sounds like Ronnie would be proud.
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Precepting at the time of a natural disaster
The Clinical Teacher
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Computed tomography in hemodynamically unstable severely injured blunt and penetrating trauma patients
The Journal of Trauma and Acute Care Surgery
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Tracking the rise and fall of Ebola in Sierra Leone
Fred Hutchinson Cancer Research Center News
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A comparative analysis of international knee documentation committee scores for common pediatric and adolescent knee injuries
Journal of Pediatric Orthopaedics
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Six-Year-Old With Altered Mental Status: No “LACk” of Clues
Pediatric Emergency Care
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Provider experience of uterine balloon tamponade for the management of postpartum hemorrhage in Sierra Leone
International Journal of Gynecology & Obstetrics
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An Unexpected Guest: A Case of Cutaneous Furuncular Myiasis: The 2013 PEMpix Photo Competition Winner
Pediatric Emergency Care
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Implementation of a hospital-integrated general practice – a successful way to reduce the burden of inappropriate emergency-department use
Swiss Medical Weekly
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Double trouble: the diagnostic dilemma of diffuse alveolar hemorrhage
American Journal of Medicine
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CT-generated radiographs in patients with pelvic ring injury: can they be used in lieu of plain radiographs?
Journal of Orthopaedic Surgery and Research
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STAAMP study to assess use of blood-clotting agent in trauma patients flown by helicopter to hospital
University of Utah Health Care
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Fracture of the lateral process of the talus in children: a kind of ankle injury with frequently missed diagnosis
Journal of Pediatric Orthopaedics
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Resuscitative endovascular balloon occlusion of the aorta might be dangerous in patients with severe torso trauma: A propensity score analysis
The Journal of Trauma and Acute Care Surgery
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Penetrating neck trauma in children: An uncommon entity described using the National Trauma Data Bank
The Journal of Trauma and Acute Care Surgery
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Complex regional pain type 1
Pediatric Emergency Care
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Differential expression of circulating microRNAs in blood and haematoma samples from patients with intracerebral haemorrhage
The Journal of International Medical Research
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Poisoning by herbs and plants: rapid toxidromic classification and diagnosis
Wilderness & Environmental Medicine
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Damage-control resuscitation and emergency laparotomy: Findings from the PROPPR study
The Journal of Trauma and Acute Care Surgery
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Femur fracture diagnosis and management aided by point-of-care ultrasonography
Pediatric Emergency Care
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Infant parenteral nutrition remains a significant source for aluminum toxicity
Journal of Parenteral and Enteral Nutrition
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Τρίτη 29 Μαρτίου 2016
EMS Agency Selects Aladtec to Resolve Issues Found by Internal Audit
Improvements to this organization are easily accomplished by implementing online employee schedule and workforce management software. Vancouver, WA - - With most businesses and organizations, there's typically room for improvement regarding how administrative tasks and processes are accomplished. With this in mind, Skamania County EMS hired a firm to come in and conduct a comprehensive audit of ...
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Firefighter/EMT - Shoreline Fire Department
SHORELINE FIRE DEPARTMENT 17525 AURORA AVENUE NORTH SHORELINE, WASHINGTON 98133 Updated: March 29, 2016 Job Classification: Firefighter/EMT Shoreline Fire Department is establishing a one year hiring list for the position of Entry Level Firefighter. This list may be extended for up to 18 months. All testing through must be completed April 29, 2016. Application Packets must be received by 4pm, April ...
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Firefighter/EMT - Cedar Hammock Fire Rescue
CEDAR HAMMOCK FIRE RESCUE 5200 26TH ST W BRADENTON, FLORIDA 34207 Updated: March 28, 2016 Classification: Firefighter/EMT Cedar Hammock Fire Rescue is building an eligibility list of applications. FireTEAM and NTN CPAT testing through National Testing Network (NTN) are both required for this listing. Salary: $38,935 Benefits: Health Insurance, FRS, Sick Leave, Vacation Leave City Information: Cedar ...
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Paramedic - Wisestaff LLC
Wisestaff is seeking multiple Paramedics at Fort Belvoir Community Hospital in Fort Belvoir, VA. All shifts are 12 hours long and run from 6 AM – 6 PM or 6 PM – 6 AM. The company does offer benefits as well. If you are interested in part time, the hourly rate is $21.00. If you are interested in full time, the hourly rate is $22.00. Technician shall be a graduate of an accredited medical ...
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Firefighter/EMT - Ocala Fire Rescue
OCALA FIRE RESCUE 410 NE 3RD ST OCALA, FLORIDA 34470 Updated: March 28, 2016 Job Classification: Firefighter/EMT Ocala Fire Rescue is currently hiring for Firefighter/EMT. All testing through National Testing Network (NTN)must be completed by April 22, 2016. General Statement of Position: This a non-supervisory position which specializes in Fire Rescue operations which include the emergency medical ...
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Wireless, Handheld Ultrasound for iOS and Android Debuts
New York, NY, March 18, 2106 (PR NEWSWIRE) – Clarius Mobile Health is showcasing the world’s first handheld ultrasound scanner with a mobile application for iOS and Android smart devices at the American Institute of Ultrasound in Medicine Conference in New York March 18-21, 2016 “Physicians have been asking for a portable ultrasound system that works with their iPhone for some time,” ...
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Abstract In this work, novel thin-film composite forward osmosis (TFC-FO) hollow fiber membranes were fabricated by modifying polyamide ac...
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Objectives: Opioids and benzodiazepines are commonly used to provide analgesia and sedation for critically ill children with cardiac disease...
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Abstract Purpose Lithium (Li), the first-line treatment of bipolar disorder, was first developed as an immediate-release form with a rou...
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Objective: Inotropic and vasopressor drugs are routinely used in critically ill patients to maintain adequate blood pressure and cardiac ou...
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Abstract The dispersion properties of Love waves are utilized for the fabrication of sensor devices in the different material environments...
