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Massive pulmonary embolism (hemodynamically unstable, defined as systolic BP90 mmHg) has significant morbidity and mortality. Point of care ultrasound (POCUS) has allowed clinicians to detect evidence of massive pulmonary embolism much earlier in the patient's clinical course, especially when patient instability precludes computerized tomography confirmation. POCUS detection of massive pulmonary embolism has traditionally been performed by physicians. This case series demonstrates four cases of massive pulmonary embolism diagnosed with POCUS performed by non-physician prehospital personnel.

Case: We discuss a patient with a penetrating knife wound to the chest who lost pulses from cardiac tamponade. Prehospital ultrasound was able to quickly identify the tamponade and a pericardiocentesis was performed using a Simplified Pneumothorax Emergency Air Release (SPEARTM) Needle (North American Rescue, LLC, USA) with subsequent return of spontaneous circulation. Discussion: Penetrating chest trauma carries significant morbidity and mortality. In traumatic cardiac arrest due to a penetrating mechanism, it is paramount that the patient be transported to a trauma center as quickly as possible. Prehospital pericardiocentesis is a potential life-saving intervention.

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Severe hypothermia (core body temperature 28°C) is life-threatening and predisposes to cardiac arrest. The comparative effectiveness of different active internal rewarming methods in an urban U.S. population is unknown. We aim to compare outcomes between hypothermic emergency department (ED) patients rewarmed conventionally using an intravascular rewarming catheter or warm fluid lavage versus those rewarmed using extracorporeal membrane oxygenation (ECMO).We performed a retrospective cohort analysis of adults with severe hypothermia due to outdoor exposure presenting to an urban ED in Minnesota, 2007-2021. The primary outcome was hospital survival. We also calculated the rewarming rate in the 4 h after ED arrival and compared these data between patients rewarmed with ECMO (the extracorporeal rewarming group) versus without ECMO (the conventional rewarming group). We repeated these analyses in the subgroup of patients with cardiac arrest.We analyzed 44 hypothermic ED patients: 25 patients in the extracorporeal rewarming group (median temperature 24.1°C, 84% with cardiac arrest) and 19 patients in the conventional rewarming group (median temperature 26.3°C, 37% with cardiac arrest; 89% received an intravascular rewarming catheter). The median rewarming rate was greater in the extracorporeal versus conventional group (2.3°C/h vs. 1.5°C/h, absolute difference 0.8°C/h, 95% confidence interval [CI] 0.3-1.2°C/h) yet hospital survival was similar (68% vs. 74%). Among patients with cardiac arrest, hospital survival was greater in the extracorporeal versus conventional group (71% vs. 29%, absolute difference 42%, 95% CI 4%-82%).Among ED patients with severe hypothermia and cardiac arrest, survival was significantly higher with ECMO versus conventional rewarming. Among all hypothermic patients, ECMO use was associated with faster rewarming than conventional methods.

Study objective Laryngeal tubes are commonly used by emergency medical services (EMS) personnel for out-of-hospital advanced airway management. The emergency department (ED) management of EMS-placed laryngeal tubes is unknown. We seek to describe ED airway management techniques, success, and complications of patients receiving EMS laryngeal tubes. Methods Using a keyword text search of ED notes, we identified patients who arrived at our ED with a laryngeal tube from 2010 through 2017. We performed structured chart and video reviews for all eligible patients. In our ED, emergency physicians perform all airway management, and there is no protocol dictating airway management for patients arriving with a laryngeal tube. Using descriptive methods, we report the techniques, success, and complications of ED airway management. Results We analyzed data on 647 patients receiving out-of-hospital laryngeal tubes, including 472 (73%) with cardiac arrest from medical causes, 75 (21%) with cardiac arrest from trauma, and 100 (15%) with other conditions. For 580 patients (89%), emergency physicians exchanged the laryngeal tube for a definitive airway in the ED. Of the 67 patients not intubated in the ED, 66 died in the ED without further airway management. Of the 580 patients intubated in the ED, orotracheal intubation was the first method attempted for 578 (>99%) and was successful on the first attempt for 515 of 578 (89%). Macintosh video laryngoscopy (88% of initial attempts) and a bougie (68% of initial attempts) were commonly used adjuncts. For 345 of 578 patients (60%), the laryngeal tube was removed before intubation attempts. For 112 of 578 patients (19%), the first intubation attempt occurred with the deflated laryngeal tube left in place. Three patients ( Conclusion In this cohort, emergency physicians successfully exchanged an out-of-hospital laryngeal tube for an endotracheal tube, using commonly available airway management techniques. ED clinicians should be familiar with techniques for exchanging out-of-hospital extraglottic airways for an endotracheal tube.

We read with interest the recent editorial, “The Hennepin Ketamine Study,” by Dr. Samuel Stratton commenting on the research ethics, methodology, and the current public controversy surrounding this study.1 As researchers and investigators of this study, we strongly agree that prospective clinical research in the prehospital environment is necessary to advance the science of Emergency Medical Services (EMS) and emergency medicine. We also agree that accomplishing this is challenging as the prehospital environment often encounters patient populations who cannot provide meaningful informed consent due to their emergent conditions. To ensure that fellow emergency medicine researchers understand the facts of our work so they may plan future studies, and to address some of the questions and concerns in Dr. Stratton’s editorial, the lay press, and in social media,2 we would like to call attention to some inaccuracies in Dr. Stratton’s editorial, and to the lay media stories on which it appears to be based.Ho JD, Cole JB, Klein LR, Olives TD, Driver BE, Moore JC, Nystrom PC, Arens AM, Simpson NS, Hick JL, Chavez RA, Lynch WL, Miner JR. The Hennepin Ketamine Study investigators’ reply. Prehosp Disaster Med. 2019;34(2):111–113

Background Body-Worn Cameras (BWCs) are not widely used in EMS. Preliminary study demonstrates a BWC effect on EMS performance. We hypothesize that there are other benefits yet to be discovered. We seek to identify other effects BWCs may have. Method This is a 30 day observation study of 20 EMS providers wearing BWCs during duty shifts in February, 2018. Metrics tracked were citizen and employee complaints and comments related to the BWC, complaint investigation, and EMS personnel feedback and education related to BWC use. Results There were no formal complaints made by citizens or employees related to BWC use. There were several neutral to positive comments made related to enhanced accuracy and transparency. There were 6 incidents that involved BWC footage requiring investigatory review. BWC immediate feedback allowed investigation closure within a few hours. In multiple cases, the BWC sparked meaningful discussion between EMS and the patient or their family. In at least 1 instance, there was de-escalation of an agitated bystander when the BWC was noticed. Conclusion EMS use of BWCs encourages transparency, accuracy, and immediate feedback to EMS personnel. They are helpful in timely complaint resolution and continuing education. Their use appears to be well-received by the public and shows promise in de-escalating some agitated persons. We encourage more study of how BWCs can improve EMS patient care. Reference Ho JD, Dawes DM, McKay EM, Taliercio JJ, White SD, Woodbury BJ, Sandefur MA and JR Miner. Effect of Body-Worn Cameras on EMS Documentation Accuracy: A Pilot Study. Prehosp Emerg Care 2017;21:263–271. Conflict of interest JD Ho serves as the medical director to Axon Enterprise, Inc. (manufacturer of body worn cameras) and owns stock in this company. Axon Enterprises supplied the cameras utilized in this study. Funding Axon Enterprise, Inc. provided the cameras utilized in this study free of charge.

To the EditorSynthetic cannabinoid receptor agonists (SCRA’s) encompass a diverse class of direct endogenous cannabinoid receptor agonists [1] with various clinical effects including: altered menta...

Central processing of complex auditory tasks requires elaborate circuitry. The auditory midbrain, or inferior colliculus (IC), epitomizes such precise organization, where converging inputs form discrete, tonotopically-arranged axonal layers. Previously in rat, we established that shaping of multiple afferent patterns in the IC central nucleus (CNIC) occurs prior to experience. This study implicates an Eph receptor tyrosine kinase and a corresponding ephrin ligand in signaling this early topographic registry. We report that EphA4 and ephrin-B2 expression patterns in the neonatal rat and mouse IC correlate temporally and spatially with that of developing axonal layers. DiI-labeling confirms projections arising from the lateral superior olive (LSO) form frequency-specific layers within the ipsilateral and contralateral mouse CNIC, as has been described in other species. Immunohistochemistry (EphA4 and ephrin-B2) and ephrin-B2 lacZ histochemistry reveal clear gradients in expression across the tonotopic axis, with most concentrated labeling observed in high-frequency, ventromedial aspects of the CNIC. Discrete patches of labeling were also discernible in the external cortex of the IC (ECIC; EphA4 patches in rat, ephrin-B2 patches in mouse). Observed gradients in the CNIC and compartmentalized ECIC expression persisted through the first postnatal week, before becoming less intense and more homogeneously distributed by the functional onset of hearing. EphA4 and ephrin-B2-positive neurons were evident in several auditory brainstem nuclei known to send patterened inputs to the IC. These findings suggest the involvement of cell-cell EphA4 and ephrin-B2 signaling in establishing order in the developing IC.

The purpose of this resource is to provide emergency medicine residents with an opportunity to practice triaging and caring for patients in a mass casualty situation. This scenario includes seven high-fidelity simulators and five standardized patients as casualties. The learners have an opportunity to improve their skills in managing and prioritizing multiple casualties, including patients with less commonly seen injuries in civilian practice, such as amputations and junctional (femoral/axillary) wounds with significant hemorrhage. The implementation of this mass casualty scenario requires a large amount of time, manpower, and energy for execution. This involves coordinating approximately 20 persons involved in the scenario as confederates, staging managers, etc. This emphasizes the importance of all personnel arriving prepared and very familiar with the scenario and their roles. It also highlights the importance of having a functional and robust backchannel communication system, as in our experience, we required at least five active channels to work seamlessly without a problem. The importance of improvisation, as in any simulation, is also important in a scenario with seven simulators and five live patients, as the increased number of mannequins and actors increases the likelihood that things may not go exactly as planned. Despite all of these logistics that can be challenging to coordinate, we feel the return on investment of giving our trainees this experiential learning experience is worth the time and effort invested, as this is an experience that they will not get very frequently and may be relied on as the chief decision maker in future mass casualty situations.