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Introduction: Survival rates after out-of-hospital cardiac arrest (OHCA) remain poor with widespread use of conventional (C) CPR. Based on pre-clinical studies showing improved cerebral flow and neurologically-intact survival, a FDA approved automated Head Up Positioning (AHUP) device for CPR was developed for use with an impedance threshold device (ITD), and manual and/or automated suction cup-based CPR. A prospective observational IRB approved registry was created to track use and clinical outcomes with this AHUP device based bundle. Hypothesis: Faster time to use of an AHUP CPR bundle improves survival to hospital discharge after OHCA versus historical controls treated with C-CPR. Methods: Registry patients from sites routinely recording time from 911 call to AHUP device placement (T 911 ) were included. C-CPR controls were from 3 prior randomized prospective CPR trials: 1) Resuscitation Outcomes Consortium Prehospital Resuscitation using an IMpedance valve and Early versus Delayed (ROC PRIMED) Study, 2) Resuscitation Outcomes Consortium Amiodarone, Lidocaine, or Placebo Study (ROC-ALPS), 3) The ResQTrial. Propensity score analysis was performed using logistic regression for baseline characteristics including age, sex, witnessed arrest, bystander CPR, shockable rhythm, and time to first responder CPR. Each AHUP patient was matched with up to 4 C-CPR patients. Results: Of 11 U.S. sites reporting AHUP CPR outcomes, 6 had time from 911 call to AHUP device placement recorded (n = 227). The model yielded a c-statistic of 0.76. Stratified by T 911 , the odds of survival with AHUP CPR were significantly higher than with C-CPR between T 911 < 7 minutes (OR 4.57, 95% CI 1.3-16.0) and T 911 < 15 minutes (OR 2.01, 95% CI 1.1-3.8). There was a time dependent effect of AHUP device placement on survival (See Figure). Conclusions: More rapid initiation of an AHUP CPR bundle resulted in improved survival to hospital discharge versus historical controls treated with C-CPR in OHCA.

Background The U.S. and worldwide death toll from opioids and other drugs has accelerated, rivaling all other causes of premature death. Emergency medical services (EMS) now has an evolving role in providing solutions. Methods EMS medical directors from the majority of the largest U.S. cities and global counterparts met to share/compile an inventory of best practices derived from their respective high-volume experiences in jurisdictions with >114 million residents combined. In turn, they created a consensus guideline document for the purposes of information-sharing among themselves and other interested parties. Results The group concluded that EMS personnel have evolving training needs with respect to new medical care challenges, but they also recommended that agencies have a special place within the collective of those hoping to provide solutions to the public health crisis of addiction and drug-related epidemics. In addition to intervening in real-time overdose events, it was recommended that they partner with other key stakeholders to develop mechanisms to end the repetitive cycle of emergency rescue followed by an almost immediate return to addictive behaviors. EMS providers should be trained to optimally communicate, refer, and direct the affected individuals to appropriate resources that will provide viable and evidence-based pathways directed toward long-term recovery. Conclusions Beyond a need to update acute medical rescue practices and improved assessment techniques, EMS providers should also learn to optimally communicate, encourage, and even participate in facilitating management continuity for the affected individuals by identifying and using the appropriate resources that will provide viable, evidence-based pathways toward sustained recovery.

INTRODUCTION: The accuracy and value of SARS CoV-2 antibody (Ab) testing has been controversial Explanations for negative follow-up Ab tests (Ab-) in PCR+ persons could be poor assays/techniques or entirely absent, transient or delayed COVID-19 Ab responses However, prior corona virus experiences have paradoxically indicated Ab- testing among younger persons and those with milder illness The purpose here was to evaluate if age or illness severity correlate with Ab- assays in persons with prior COVID-19 PCR+ tests METHODS: Part of an on-going study, 2 dissimilar EMS agencies (fire-based vs 3rd service) in 2 far-distanced U S cities with contrasting populations, both evaluated prior PCR+ employees with IgM/IgG testing, but each used 2 different lateral flow chromatographic immunoassay (LFCIA) products Among 70 volunteers at Site 1, 39 were a reference group (RG) from the general population with no prior COVID-19 symptoms or testing (Sx-/NoPCR group) The other 48 (PCR+) principals at both sites had prior nasal swab PCR+ tests At a later date (2-8 weeks), the 48 received IgM/IgG fingerstick LFCIA testing and were surveyed (both sites) for pre-selected Sx categories, illness severity indicators, age, sex and date of PCR+ test RESULTS: Despite distinct differences in local demographics, agencies and assay products, findings were strikingly similar at both sites Of 48 prior PCR+ subjects, roughly 30% at either site (n=15/48;31 2%) were IgM-/IgG- (32 2% at site 1;29 4% at site 2) The mean age for the Sx-/NoPCR RG (n=39, all testing Ab-) was 45 51 yrs, range (R) 26-75 and similarly 43 97 (R=21- 81) for 33 PCR+/Ab+ subjects (p=NS) However, for those with prior PCR+ tests but Ab-, the mean age was 33 9 yrs (R=21-50);2-tailed p=0 009 vs PCR+/Ab+ and 0 003 vs RG Differences were near-identical within each site: Site 1 = 44 7 yrs, R=21-81 vs 34 7 R=21-50 (p=0 048;0 021 vs RG);Site 2: 42 75, R 25-62 vs 32 2, R=27-39 (p=0 048;0 003 vs RG) At both sites, trends were evolving for Ab- in milder disease, women and shorter PCR to Ab testing intervals CONCLUSIONS: Using different IgM/IgG LFCIA products in two highly-contrasted settings, 30% of persons with prior COVID-19 PCR+ tests were Ab- at both sites and, in either venue, those PCR+/Ab- persons were significantly younger than PCR+/Ab+ counterparts

Background: After endovascular therapy (EVT) became standard of care for acute ischemic stroke (AIS) in 2015, emergency medical services (EMS) in 3 urban southeast Florida counties modified their transport protocols for suspected AIS. In 2015, Broward (BC) and Palm Beach counties (PBC) phased in EMS transport of all stroke alerts to state-attested comprehensive stroke centers (CSC). Miami-Dade (MDC) adopted a severity-based protocol. Methods: The impact of EMS policy changes was assessed using the AHA Get with the Guidelines-Stroke data prospectively collected for the Florida-Puerto Rico Stroke Registry involving 35,794 AIS cases in the 3 counties with 27 CSC between 2010 and 2016. Results: The percent of patients transported directly by EMS from scene to CSCs in BC and PBC rose from 34% and 13% during 2010, to 97% and 86%, respectively, in 2016 (p=0.002). In MDC, it increased from 62% to 77%. In 2016, the percentage of AIS patients that presented to CSC as transfers from primary stroke centers (PSC) was 5% in BC, 8% in PBC, and 12% in MDC. Of all patients receiving IV tPA in 2016, 81% were transported by EMS and 87 % of IV tPA treatment was administered in a CSC. From 2010 to 2016, IV tPA treatment increased from 8% to 18% in CSC vs. 8% to 12% in PSC (p=0.41). By 2016 the mean door to needle time was 13 min shorter in CSCs (p Conclusion: Modifying EMS policies to transport most suspected AIS patients directly to CSCs was associated with higher rates of IV tPA treatment, shorter intervals to IV tPA after symptom onset, faster arrival times for EVT evaluation and higher rates of EVT compared to patients triaged to PSCs. Based on these findings, directly transporting suspected AIS patients to CSC may be a successful strategy to expedite stroke care interventions in urban centers with high CSC density.

Introduction: Violent and agitated patients pose a serious challenge for emergency medical services (EMS) personnel. Rapid control of these patients is paramount to successful prehospital evaluation and also for the safety of both the patient and crew. Sedation is often required for these patients, but the ideal choice of medication is not clear. The objective is to demonstrate that ketamine, given as a single intramuscular injection for violent and agitated patients, including those with suspected excited delirium syndrome (ExDS), is both safe and effective during the prehospital phase of care, and allows for the rapid sedation and control of this difficult patient population. Methods: We reviewed paramedic run sheets from five different catchment areas in suburban Florida communities. We identified 52 patients as having been given intramuscular ketamine 4mg/kg IM, following a specific protocol devised by the EMS medical director of these jurisdictions, to treat agitated and violent patients, including a subset of which would be expected to suffer from ExDS. Twenty-six of 52 patients were also given parenteral midazolam after medical control was obtained to prevent emergence reactions associated with ketamine. Results: Review of records demonstrated that almost all patients (50/52) were rapidly sedated and in all but three patients no negative side effects were noted during the prehospital care. All patients were subsequently transported to the hospital before ketamine effects wore off. Conclusion: Ketamine may be safely and effectively used by trained paramedics following a specific protocol. The drug provides excellent efficacy and few clinically significant side effects in the prehospital phase of care, making it an attractive choice in those situations requiring rapid and safe sedation especially without intravenous access. [West J Emerg Med. 2014;15(7):–0.]

Hypothesis: The withholding/delay of positive pressure ventilation can improve out of hospital adult primary cardiac arrest survival. Methods: All adult primary cardiac arrest victims in a single municipal (Sate of Florida) Fire/Rescue service in whom resuscitation attempts were made were initially given chest compressions only. Positive pressure ventilation was withheld until the first of either 10 minutes or return of spontaneous circulation (ROSC). Continuous uninterrupted chest compressions were an integral part of the protocol. Primary cardiac arrest was defined as an arrest not felt to be due to hypoxia. The Florida State EMSTARS (EMS Tracking and Reporting System) database provided the information for statewide average ROSC. Results: Over a two-year period the ROSC and neurologically intact recovery rate was dramatically improved over Florida State average controls. The 2013 total ROSC rate was 40% (18/45) compared to a Florida State average ROSC of 16.7%. The 2014 primary cardiac arrest ROSC rate was 51.5% (17/33) with 29.4% of the ROSC patients or 15.2% of the total achieving neurologically intact survival. This compares to the 2014 Florida State average ROSC of 17.9%. Conclusion: Delayed positive pressure ventilation seems to be associated with both improved ROSC and neurologically intact survival in adult out of hospital primary cardiac arrest. Further study is warranted to determine the extent of this association.

Background: The frequency of complications in patients with cocaine-associated myocardial infarction is unknown. This study was performed to determine the short-term morbidity and mortality secondary to cocaine-associated myocardial infarction. Methods: We performed a retrospective cohort study at 29 hospital centers throughout the United States. Patients with cocaine-associated myocardial infarction that occurred between 1987 and 1993 were identified through record review. The primary outcome measures were inhospital mortality and the incidence and timing of major cardiovascular complications. Results: Cocaine-associated myocardial infarction was identified 136 times in 130 patients. Patients were generally young (mean age, 38 years), nonwhite (72%), tobacco smokers (91%) with a history of cocaine use in the past 24 hours (88%). The initial electrocardiogram disclosed infarction in 44% and ischemia in an additional 18% of patients. Myocardial infarctions were evenly distributed between anterior (45%) and inferior (44%) and were most often non—Q-wave (61%). Complications occurred 64 times in 49 patients (36%; 95% confidence interval, 28% to 44%), including congestive heart failure in nine patients, ventricular tachycardia in 23 patients, supraventricular tachycardia in six patients, and brady-dysrhythmias in 26 patients. Most patients who had complications (90%) had them within 12 hours of presentation. Acute in-hospital mortality was 0% (95% confidence interval, 0% to 2%). Conclusions: The mortality of patients hospitalized with cocaine-associated myocardial infarction was low. The majority of complications occurred within 12 hours of presentation. (Arch Intern Med. 1995;155:1081-1086)