The American Board of Emergency Medicine (ABEM) gathers extensive background information on emergency medicine residency programs and the residents training in those programs. We present the 2017 ...annual report on the status of US emergency medicine training programs.
Hyperglycemia is associated with poor outcomes in critically-ill patients. This has implications for prognostication of patients with out-of-hospital cardiac arrest (OHCA) and for post-resuscitation ...care. We assessed the association of hyperglycemia, on field point-of-care (POC) testing, with survival and neurologic outcome in patients with return of spontaneous circulation (ROSC) after OHCA.
This was a retrospective analysis of data in a regional cardiac care system from April 2011 through December 2017 of adult patients with OHCA and ROSC who had a field POC glucose. Patients were excluded if they were hypoglycemic (glucose <60 mg/dl) or received empiric dextrose. We compared hyperglycemic (glucose >250 mg/dL) with euglycemic (glucose 60–250 mg/dL) patients. Primary outcome was survival to hospital discharge (SHD). Secondary outcome was survival with good neurologic outcome (cerebral performance category 1 or 2 at discharge). We determined the adjusted odds ratios (AORs) for SHD and survival with good neurologic outcome.
Of 9008 patients with OHCA and ROSC, 6995 patients were included; 1941 (28%) were hyperglycemic and 5054 (72%) were euglycemic. Hyperglycemic patients were more likely to be female, of non-White race, and have an initial non-shockable rhythm compared to euglycemic patients (p < 0.0001 for all). Hyperglycemic patients were less likely to have SHD compared to euglycemic survivors, 24.4% vs 32.9%, risk difference (RD) −8.5% (95 %CI −10.8%, −6.2%), p < 0.0001. Hyperglycemic survivors were also less likely to have good neurologic outcome compared to euglycemic survivors, 57.0% vs 64.6%, RD −7.6% (95 %CI −12.9%, −2.4%), p = 0.004. The AOR for SHD was 0.72 (95 %CI 0.62, 0.85), p < 0.0001 and for good neurologic outcome, 0.70 (95 %CI 0.57, 0.86), p = 0.0005.
In patients with OHCA, hyperglycemia on field POC glucose was associated with lower survival and worse neurologic outcome.
With the establishment and growth of the Emergency Medical Services (EMS) subspecialty, significant attention has been focused on clinical activities performed by EMS physicians in the ...out-of-hospital environment. An EMS fellowship includes special operations education to develop preparedness for responding to field situations requiring physician expertise. With only a thousand Board Certified EMS physicians in North America, EMS physicians may not be available 24 h per day to respond to field emergencies. Non-EMS physicians with minimal experience in prehospital or austere care may be called upon to respond to complex prehospital emergencies requiring advanced skills. The Los Angeles County EMS Agency implemented a policy in 1992 to establish Hospital Emergency Response Teams (HERT) as a regional resource to provide time-critical, specialized prehospital services within an EMS system. Activation of the HERT is rare, most frequently prompted by need for field amputation to enable extrication. We describe one such incident of a field intervention by HERT and detail the staffing, training, and equipment considerations within our large regional EMS system.With the establishment and growth of the Emergency Medical Services (EMS) subspecialty, significant attention has been focused on clinical activities performed by EMS physicians in the out-of-hospital environment. An EMS fellowship includes special operations education to develop preparedness for responding to field situations requiring physician expertise. With only a thousand Board Certified EMS physicians in North America, EMS physicians may not be available 24 h per day to respond to field emergencies. Non-EMS physicians with minimal experience in prehospital or austere care may be called upon to respond to complex prehospital emergencies requiring advanced skills. The Los Angeles County EMS Agency implemented a policy in 1992 to establish Hospital Emergency Response Teams (HERT) as a regional resource to provide time-critical, specialized prehospital services within an EMS system. Activation of the HERT is rare, most frequently prompted by need for field amputation to enable extrication. We describe one such incident of a field intervention by HERT and detail the staffing, training, and equipment considerations within our large regional EMS system.
Persons experiencing homelessness (PEH) are among the most vulnerable populations and experience significant health disparities. Nationally, PEH utilize Emergency Medical Services (EMS) at ...disproportionately higher rates than their housed peers. Developing optimal strategies to care for PEH has become critically important. However, limited data exists on best practices, challenges, and experiences of providing care to PEH. The objective of this study was to describe the experiences, challenges and perspectives of operational EMS agency medical directors in Los Angeles (LA) County as they confront the homelessness crisis.
We performed a cross-sectional survey of 9-1-1 operational EMS agency medical directors in LA County, which has one of the largest populations of PEH nationally. Twenty-nine 9-1-1 operational EMS agencies operate in LA County. The link to an anonymous, web-based survey examining documentation, training, resources, operational impact, and care challenges was emailed to medical directors with three reminders during the study period (4/19/2023-9/15/2023).
Three quarters (75.9%; 22/29) of operational EMS agencies responded to the survey, with all questions answered in 69% (20/29) of surveys. Of these, 68.2% (15/22) of agencies document housing status and 75% (15/20) agreed or strongly agreed that homelessness presents operational challenges. No operational EMS agency reported adequate EMS clinician training on homelessness. Operational EMS agencies most commonly utilized domestic violence resources (43%, 9/21), social services (38%, 8/21), and law enforcement (38%, 8/21) services to assist PEH. Referrals were limited by accessibility (86%, 18/21), time (52%, 11/21), lack of awareness (52% 11/21) and lack of mandates (52%, 11/21). All operational EMS agencies agreed or strongly agreed that mental health and substance use disorders are major issues for PEH. The most common daily challenges reported were mental health (55%, 11/20), substance use (55%, 11/20), and patient resistance (35%, 7/20).
In LA County, EMS agencies experience important operational and clinical challenges in caring for PEH, with limited resources, minimal training, and high rates of substance use disorders and mental health comorbidities. Further prehospital research is essential to standardize documentation of housing status, to identify areas for intervention, increase linkage to services, and define best practices.
To determine the geographic accessibility of emergency departments (EDs) with high pediatric readiness by assessing the percentage of US children living within a 30-minute drive time of an ED with ...high pediatric readiness, as defined by collaboratively developed published guidelines.
In this cross-sectional analysis, we examined geographic access to an ED with high pediatric readiness among US children. Pediatric readiness was assessed using the weighted pediatric readiness score (WPRS) of US hospitals based on the 2013 National Pediatric Readiness Project (NPRP) survey. A WPRS of 100 indicates that the ED meets the essential guidelines for pediatric readiness. Using estimated drive time from ZIP code centroids, we determined the proportions of US children living within a 30-minute drive time of an ED with a WPRS of 100 (maximum), 94.3 (90th percentile), and 83.6 (75th percentile).
Although 93.7% of children could travel to any ED within 30 minutes, only 33.7% of children could travel to an ED with a WPRS of 100, 55.3% could travel to an ED with a WPRS at or above the 90th percentile, and 70.2% could travel to an ED with a WPRS at or above the 75th percentile. Among children within a 30-minute drive of an ED with the maximum WPRS, 90.9% lived closer to at least 1 alternative ED with a WPRS below the maximum. Access varied across census divisions, ranging from 14.9% of children in the East South Center to 56.2% in the Mid-Atlantic for EDs scoring a maximum WPRS.
A significant proportion of US children do not have timely access to EDs with high pediatric readiness.
We developed evidence-based recommendations for prehospital evaluation and treatment of adult patients with respiratory distress. These recommendations are compared with current protocols used by the ...33 local emergency medical services agencies (LEMSA) in California.
We performed a review of the evidence in the prehospital treatment of adult patients with respiratory distress. The quality of evidence was rated and used to form guidelines. We then compared the respiratory distress protocols of each of the 33 LEMSAs for consistency with these recommendations.
PICO (population/problem, intervention, control group, outcome) questions investigated were treatment with oxygen, albuterol, ipratropium, steroids, nitroglycerin, furosemide, and non-invasive ventilation. Literature review revealed that oxygen titration to no more than 94-96% for most acutely ill medical patients and to 88-92% in patients with acute chronic obstructive pulmonary disease (COPD) exacerbation is associated with decreased mortality. In patients with bronchospastic disease, the data shows improved symptoms and peak flow rates after the administration of albuterol. There is limited data regarding prehospital use of ipratropium, and the benefit is less clear. The literature supports the use of systemic steroids in those with asthma and COPD to improve symptoms and decrease hospital admissions. There is weak evidence to support the use of nitrates in critically ill, hypertensive patients with acute pulmonary edema (APE) and moderate evidence that furosemide may be harmful if administered prehospital to patients with suspected APE. Non-invasive positive pressure ventilation (NIPPV) is shown in the literature to be safe and effective in the treatment of respiratory distress due to acute pulmonary edema, bronchospasm, and other conditions. It decreases both mortality and the need for intubation. Albuterol, nitroglycerin, and NIPPV were found in the protocols of every LEMSA. Ipratropium, furosemide, and oxygen titration were found in a proportion of the protocols, and steroids were not prescribed in any LEMSA protocol.
Prehospital treatment of adult patients with respiratory distress varies widely across California. We present evidence-based recommendations for the prehospital treatment of undifferentiated adult patients with respiratory distress that will assist with standardizing management and may be useful for EMS medical directors when creating and revising protocols.
The American Academy of Pediatrics established the Pediatric Education for Prehospital Professionals (PEPP) Course in 1998. A national PEPP Task Force rolled out the first courses in 2000, and PEPP ...rapidly became a foundational pediatric knowledge source in prehospital education. The backbone of the PEPP course is the pediatric assessment triangle (PAT), a simple assessment tool to help determine if an infant or child is "sick" or "not sick", to identify the likely type of pathophysiology, and to gauge the urgency for intervention. The PAT has been validated in multiple studies as a reliable tool for emergency triage and for guiding initial management of children in both prehospital and emergency settings. Over 400,000 emergency medical services clinicians have taken the PEPP course, and the PAT has been integrated into life support courses, emergency pediatrics training, and pediatric assessment protocols worldwide. We describe the creation and successful implementation of the first national prehospital pediatric emergency care course, including the integration and widespread dissemination of an innovative assessment paradigm for pediatric emergency care education and training.
In the United States emergency medical services (EMS) protocols vary widely across jurisdictions. We sought to develop evidence-based recommendations for the prehospital evaluation and treatment of a ...patient with an acute change in mental status and to compare these recommendations against the current protocols used by the 33 EMS agencies in the State of California.
We performed a literature review of the current evidence in the prehospital treatment of a patient with altered mental status (AMS) and augmented this review with guidelines from various national and international societies to create our evidence-based recommendations. We then compared the AMS protocols of each of the 33 EMS agencies for consistency with these recommendations. The specific protocol components that we analyzed were patient assessment, point-of-care tests, supplemental oxygen, use of standardized scoring, evaluating for causes of AMS, blood glucose evaluation, toxicological treatment, and pediatric evaluation and management.
Protocols across 33 EMS agencies in California varied widely. All protocols call for a blood glucose check, 21 (64%) suggest treating adults at <60mg/dL, and half allow for the use of dextrose 10%. All the protocols recommend naloxone for signs of opioid overdose, but only 13 (39%) give specific parameters. Half the agencies (52%) recommend considering other toxicological causes of AMS, often by using the mnemonic AEIOU TIPS. Eight (24%) recommend a 12-lead electrocardiogram; others simply suggest cardiac monitoring. Fourteen (42%) advise supplemental oxygen as needed; only seven (21%) give specific parameters. In terms of considering various etiologies of AMS, 25 (76%) give instructions to consider trauma, 20 (61%) to consider stroke, and 18 (55%) to consider seizure. Twenty-three (70%) of the agencies have separate pediatric AMS protocols; others include pediatric considerations within the adult protocol.
Protocols for patients with AMS vary widely across the State of California. The evidence-based recommendations that we present for the prehospital diagnosis and treatment of this condition may be useful for EMS medical directors tasked with creating and revising these protocols.
Background: Intranasal (IN) midazolam allows for rapid, painless treatment of pediatric seizures in the prehospital setting and may be a preferred administration route if determined to be ...non-inferior to intravenous (IV) or intramuscular (IM) routes. We sought to evaluate the effectiveness of IN midazolam for terminating prehospital pediatric seizures compared to midazolam administered by alternate routes. Methods: We performed a retrospective, non-inferiority analysis using data from a regional Emergency Medical Services (EMS) database. We included pediatric patients ≤ 14 years treated with midazolam (0.1 mg/kg) by EMS for non-traumatic seizures. The primary outcome was the proportion of patients requiring redosing of midazolam after initial treatment with IN midazolam compared to those that received IV or IM midazolam. We established a priori a risk difference of 6.5% as the non-inferiority margin. Results: We evaluated outcomes from 2,034 patients (median age 6 years interquartile range 3 − 10 years, 55% male). Initial administration routes were 461 (23%) IN, 547 (27%) IM, 1024 (50%) IV, and 2 (0.1%) intraosseous (IO). Midazolam redosing occurred in 116 patients (25%) who received IN midazolam versus 222 patients (14%) treated initially with midazolam via alternate routes (risk difference 11% 95%CI 7 − 15%). The age-adjusted odds ratio for redosing midazolam after intranasal administration compared to alternate route administration was 2.0 (95% CI 1.6 − 2.6). Conclusion: Prehospital treatment of pediatric seizure with intranasal midazolam was associated with increased frequency of redosing compared to midazolam administered by other routes, suggesting that 0.1 mg/kg is a subtherapeutic dose for intranasal midazolam administration.
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