Considerable controversy persists regarding the optimal means and indications for airway management, the utility of paralytic agents to facilitate intubation, and the indications for advanced airway ...access techniques in the prehospital setting. To describe the use of intubation and advanced airway management in a system with extensive experience with both the use of paralytic agents and surgical airway techniques, a retrospective review was conducted of all prehospital airway procedures from January 1997 through November 1999. Data collected included demographics, airway management techniques, use of paralytic agents, and immediate outcome. The results showed there were 2700 patients intubated out of 50,118 patient encounters (5.4%). The indications for intubation included medical emergency in 82% of patients and traumatic injury in 18%. Fifty percent of patients were intubated with the use of succinylcholine. The overall oral intubation success rate was 98.4% and definitive airway access was achieved in all but 12 patients (0.6%), with 30 patients receiving surgical airway access (1%). The successful intubation rate for patients receiving paralytic agents was 97.8%. Previously published rates of prehospital surgical airway access range from 3.8 to 14.9% of patients. In this study, only 1.1% of patients required a surgical airway. We attribute this low rate to the use of paralytic agents. The availability of paralytic agents also allows expansion of the indications for prehospital airway control.
Since the implementation of a paramedic system in Seattle, yearly survival rates from out-of-hospital cardiac arrest due to ventricular fibrillation have averaged 25% without any significant increase ...over the years. Outcome for cardiac arrest associated with other rhythms has been poor: when asystole was the first rhythm recorded, only 1% of patients survived; when electromechanical dissociation was initially present, only 6% survived. For cases of electromechanical dissociation, neither the type of rhythm nor the rate appear to influence outcome. Survival from ventricular fibrillation can be improved by shortening the delay to initiation of CPR and to defibrillation. When outcome in 244 witnessed arrests was related to the times to beginning CPR and to initial defibrillation, mortality increased 3% each minute until CPR was begun and 4% a minute until the first shock was delivered. New strategies that minimize delays appear to have the greatest promise for improving survival after cardiac arrest.
Since 1970, Seattle Fire Department paramedics have treated 5,120 victims of out-of-hospital ventricular fibrillation (VF). During the past decade, there was an impressive decline in the annual ...incidence of VF, probably reflecting a general reduction in age-adjusted mortality attributed to coronary heart disease. Since 1975, annual survival rates to hospital discharge fluctuated between 24% and 33%, averaging 28.9%. In spite of continuing efforts to improve basic and advanced life support, survival rates have not risen concomitantly. Since the early 1970s, average ages of victims have increased from 63.4 to 66.1 years (p less than 0.0001). Additionally, in survivors of VF arrest, habitual cigarette smoking has become much less frequent (48% versus 31%, p less than 0.0001). Longevity of VF survivors has improved in recent years, with 1- and 5-year survival rates increasing from 74% and 44%, respectively, for those resuscitated during 1970-1975 to 83% and 57%, respectively, for those resuscitated during 1982-1987 (p less than 0.0001). It is likely that medical or surgical therapy and improved hygienic measures have contributed to the better outcomes. The vast majority of resuscitated victims have not had symptomatic ventricular arrhythmias before VF. Accordingly, current efforts to control such arrhythmias will not have an important impact on the community incidence of sudden cardiac death. Successful strategies for further containment will likely be those that address the problem of coronary atherogenesis, although medical and surgical therapies may also have a role. Additionally, it is timely to evaluate the widespread use of automated defibrillators by persons other than emergency medical technicians or paramedics.
Eighty-seven patients who had out-of-hospital cardiac arrests received defibrillating shocks delivered by minimally trained first responders before the arrival of paramedics in a city with short ...emergency response times. Their outcomes were compared with those of 370 other victims who received only basic life support by first responders until paramedics arrived. Survival was improved by early defibrillation in cases in which there was a delay in initiating cardiopulmonary resuscitation and in which paramedic response times exceeded 9 min; there was 62% survival after early defibrillation by first responders and 27% if first responders provided only basic life support (p less than .02). Neurologic recovery was also improved after early defibrillation. Eighteen of 46 resuscitated patients (39%) receiving early defibrillation were awake at 24 hr compared with 49 of 204 patients (24%) who received only basic life support while awaiting paramedics (p less than .02). Incorporating defibrillation as part of basic life support can reduce both mortality and morbidity from cardiac arrest, even in cities with established, rapidly responding emergency care systems.
We examined the relation between age and outcomes in patients treated for out-of-hospital cardiac arrest in Seattle, Wash. Considering all out-of-hospital cardiac arrests treated by paramedics over a ...recent 5-year period, 386 (27%) of 1405 consecutive patients aged 70 years or older were resuscitated and admitted to a hospital vs 474 (29%) of 1624 younger patients; 140 elderly patients (10%) were discharged alive vs 223 younger patients (14%). Of the 140 elderly patients, 112 went home and 28 went to a nursing home. Considering only patients whose initial rhythms were ventricular fibrillation, the percent of patients discharged alive was substantially higher: 120 (24%) of 493 for elderly patients and 194 (30%) of 639 for younger patients. Elderly patients can benefit from attempted resuscitation from out-of-hospital cardiac arrest.
Endotracheal intubation by emergency medical services (EMS) personnel in the prehospital setting decreases morbidity and helps to improve the outcome of critically ill patients, especially those with ...cardiac or respiratory arrest, multiple injuries, or severe head trauma. The endotracheal tube facilitates better oxygenation and ventilation because it enhances lung inflation and protects the lungs from aspiration. No other alternative modality is as efficacious. Compared to physicians in general, properly instructed, well-supervised paramedics can be trained to perform this procedure safely and more efficiently in the emergency setting. The use of the endotracheal tube in the prehospital setting should be strongly encouraged and the training of EMS personnel in this skill should be given high priority.
Abstract
Background. Emergency airway management is an important component of resuscitation of critically ill patients. Multiple studies demonstrate variable endotracheal intubation (ETI) success by ...prehospital providers. Data describing how many ETI training experiences are required to achieve high success rates are sparse. Objectives. To describe the relationship between the number of prehospital ETI experiences and the likelihood of success on subsequent ETI and to specifically look at uncomplicated first-pass ETI in a university-based training program with substantial resources. Methods. We conducted a secondary analysis of a prospectively collected cohort of paramedic student prehospital intubation attempts. Data collected on prehospital ETIs included indication, induction agents, number of direct laryngoscopy attempts, and advanced airway procedures performed. We used multivariable generalized estimating equations (GEE) analysis to determine the effect of cumulative ETI experience on first-pass and overall ETI success rates. Results. Over a period of three years, 56 paramedic students attempted 576 prehospital ETIs. The odds of overall ETI success were associated with cumulative ETI experience (odds ratio OR 1.097 per encounter, 95% confidence interval CI = 1.026-1.173, p = 0.006). The odds of first-pass ETI success were associated with cumulative ETI experience (OR 1.061 per encounter, 95% CI = 1.014-1.109, p = 0.009). Conclusion. In a training program with substantial clinical opportunities and resources, increased ETI success rates were associated with increasing clinical exposure. However, first-pass placement of the ETT with a high success rate requires high numbers of ETI training experiences that may exceed the number available in many training programs.
The amplitude of ventricular fibrillation found initially in 394 patients was compared to clinical and logistical findings at the time of cardiac arrest. Peak-to-peak amplitude averaged 0.55 +/- 0.25 ...mV; a very low amplitude (0.2 mV or less) or "fine" fibrillation was present in 66 patients (17%). The amplitude was not found to be related to clinical histories, but depended on the length of the period from collapse until start of basic life support (p = 0.004) and the delay until assessment by paramedics (p = 0.001). Survival rates were strongly associated with amplitude: only 4 patients (6%) with fine ventricular fibrillation survived, compared to 117 or 328 patients (36%) in whom the initial amplitude was higher (p less than 0.001). Patient outcome related to amplitude even after adjusting for clinical history and logistical delays (p less than 0.005). We conclude that fine ventricular fibrillation is in part the result of delay in initiation of treatment, and that fibrillation amplitude is a powerful indicator of outcome after cardiac arrest.
Young adults, 18-20 years of age, admitted to a trauma center via the emergency department, were studied to determine if they had been drinking prior to their injury event. The prevalence of ...self-reported chronic alcohol problems was examined using the short Michigan Alcohol Screening Test (SMAST). Of the 319 subjects, 131 (41%) tested positive for alcohol, including about one-half of those with intentional injuries and 38% with unintentional injuries. Approximately 22% had blood alcohol concentrations of 100 mg/dL or more, indicating they were legally intoxicated at the time of their injury. Of study subjects who completed the SMAST, 49% attained scores suggesting potential or probable alcoholism, and 20% had already sought some type of treatment, despite their young age. Health-care practices and policies related to these findings include routine screening of trauma patients for alcohol abuse and integration of chemical dependency intervention services with trauma care.
Study objectives: Little is known regarding the potential effects of emergency medical services (EMS) on total heart disease mortality. Although EMS may provide health benefits in less acute cardiac ...conditions, its immediate, measurable, and direct effect on heart disease mortality is through resuscitation of persons suffering out-of-hospital cardiac arrest. The purpose of this study was to examine the involvement and potential mortality benefit of out-of-hospital EMS care of cardiac arrest on community heart disease mortality. Methods: The investigation was an observational study of all persons with death events resulting from heart disease as defined by heart disease deaths and deaths averted (persons successfully resuscitated from out-of-hospital cardiac arrest by EMS) in a single county from January 1, 2000, through December 31, 2000. The county of study has a population of nearly 2 million people and is composed of urban, suburban, and rural components. State vital records and EMS reports were used to ascertain deaths resulting from heart disease and deaths averted. Results: In the year 2000, 3,577 persons died as a result of heart disease, and 128 persons were successfully resuscitated and discharged from the hospital, for a total of 3,705 death events. EMS responded to 39% (1,428/3,705) of all heart disease death events and 57% (1,428/2,516) of out-of-hospital events, resulting in a 3.5% (128/3,705) reduction in overall heart disease mortality and a 5.1% (128/2,516) reduction in out-of-hospital mortality. Conclusion: EMS was involved in the majority of out-of-hospital heart disease death events, resulting in a measurable reduction in heart disease mortality. Ann Emerg Med. 2003;41:494-499.
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