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Motor vehicle intrusion (MVI) is one of the field triage criteria recommended by the American College of Surgeons Committee of Trauma (ACS-COT) and Centers for Disease Control and Prevention (CDC). However, the evidence supporting its validity is scarce. The purpose of this study was to evaluate the validity of this criterion and assess its impact on overtriage or undertriage.This was a retrospective study based on the Los Angeles County Trauma and Emergency Medicine Information System (TEMIS) Trauma database. Included in the analysis were patients with MVI as the sole criterion for trauma center triage. Physiological characteristics, severity of injury, and outcomes of the MVI patients were compared between different age groups. Further, a logistic regression model was used to identify factors significantly associated with the need for trauma center resources.During the period 2002-2012, a total of 10,554 trauma patients involved in motor vehicle crashes had documentation of MVI. A subgroup of 3998 patients (37.9%) did not meet any other criteria that require immediate transportation to a designated trauma center. Only 0.7% of these patients had hypotension and 0.1% had deterioration of the Glasgow Coma Scale on admission to the emergency room. Overall, 18.8% of patients required trauma center resources defined as intubation in the emergency room, certain surgical procedures, in-hospital death, or intensive care unit admission. Age ≥65 years, male gender, prehospital heart rate100/min, and systolic blood pressure110 mmHg were significantly associated with the need for trauma center resources.The MVI itself did not appear to be a strong indicator for the use of trauma center resources and is associated with excessive overtriage. However, age65 years, systolic blood pressure110 mmHg, and heart rate100/min were significant predictors for the need of trauma center resources. The MVI criterion should be refined for better utilization of trauma center resources.

Background. Prehospital identification of STEMI and activation of the catheterization lab can improve door-to-balloon (D2B) times but may lead to decreased specificity and unnecessary resource utilization. The purpose of this study was to examine the effect of electrocardiogram (ECG) transmission on false-positive (FP) cath lab activations and time to reperfusion. Methods. This is a retrospective cohort from a registry in a large metropolitan area with regionalized cardiac care and emergency medical services (EMS) with ECG transmission capabilities. Thirty-four designated STEMI receiving centers (SRC) contribute to this registry, from which patients with a prehospital ECG software interpretation of myocardial infarction (MI) indicated by ****Acute MI****, or manufacturer equivalent, were identified between April 2011 and September 2013. Frequency of FP field activations (defined as not resulting in emergent percutaneous coronary intervention [PCI] or referral for CABG during hospital admission) for patients with ECG transmission received by the SRC was compared to a reference group without successful ECG transmission. FP field activations were compared to the baseline frequency of FP ED activations. We hypothesized that successful transmission would reduce FP field activation to ED activation levels. Door-to-balloon and first medical contact-to-balloon (FMC2B) times were compared. The protocol for field cath lab activation varied by institution. Results. There were 7,768 patients presenting with a prehospital ECG indicating MI. The ECG was received by the SRC for 2,156 patients (28%). Regardless of transmission, the cath lab was activated 77% of the time; this activation occurred from the field in 73% and 74% of the activations in the transmission and reference group, respectively. The overall proportion of FP activation was 57%. Among field activations, successful ECG transmission reduced the FP activation rate compared to without ECG transmission, 55% vs. 61% (RD = −6%, 95%CI −9, −3%). This led to an overall system reduction in FP activations of 5% (95%CI 2, 8%). ECG transmission had no effect on D2B and FMC2B time. Conclusion. Prehospital ECG transmission is associated with a small reduction in false-positive field activations for STEMI and had no effect on time to reperfusion in this cohort. Key words: emergency medical services; myocardial infarction; myocardial reperfusion; electrocardiography

Oxygen desaturation occurs frequently in the course of prehospital rapid sequence intubation (RSI) and is associated with increased morbidity and mortality. Preoxygenation with positive pressure ventilation by bag valve mask may delay the onset of desaturation. The purpose of this study was to evaluate implementation of a targeted preoxygenation protocol including the use of positive pressure ventilation on desaturation events and intubation success during air medical RSI.The RSI air medical program airway training model was modified to target an oxygen saturation as measured by pulse oximetry value of ≥ 93% before initial laryngoscopy. A review of oxygen saturation as measured by pulse oximetry tracings was performed for 2 years before and 2 years after implementation of this protocol. The incidence of desaturation events and overall intubation success rates were compared before and after the intervention.One hundred fifty-five RSI procedures were evaluated over the study period. Desaturation events decreased from 58% in the 2 years before algorithm changes to 28% in the first year and 14% in the second year after implementation (P.01). Intubation success rates increased from 89% to 98% (P.01). There were no self-reports of aspiration events during the study period.A preoxygenation protocol dramatically reduced the incidence of desaturation events and increased intubation success without an increase in the number of reported aspiration events.

The aim of this study was to evaluate the treatment and outcomes of patients with ST-segment elevation myocardial infarctions complicated by out-of-hospital cardiac arrest in a regional system of care. In this retrospective study, the effect of the absence of an initial shockable arrest rhythm was analyzed. The primary end point of survival with good neurologic outcome in patients with and without an initial shockable arrest rhythm was adjusted for age, witnessed arrest, bystander cardiopulmonary resuscitation, and treatment with therapeutic hypothermia and percutaneous coronary intervention. One-hundred sixty-eight of 348 patients (49%) survived to hospital discharge. Patients with a shockable initial rhythm were more likely to receive therapeutic hypothermia (48% vs 37%, risk ratio 1.2, 95% confidence interval [CI] 1.0 to 1.5) and to be treated in the cardiac catheterization laboratory (80% vs 43%, risk ratio 2.8, 95% CI 2.0 to 3.8). The likelihood of survival with good neurologic outcome in patients with a shockable initial rhythm compared with those presenting without a shockable rhythm was 4.8 (95% CI 2.7 to 8.7). In patients who underwent percutaneous coronary intervention, the likelihood of survival with good neurologic outcome was higher (risk ratio 2.7, 95% CI 1.1 to 6.8) in those with a shockable rhythm. In conclusion, the absence of an initial shockable rhythm in patients with ST-segment elevation myocardial infarctions plus out-of-hospital cardiac arrest is associated with significantly worse survival and neurologic outcome. These differences persist despite application of therapies including therapeutic hypothermia and percutaneous coronary intervention within a regionalized system of care.

Background Reducing delays in time to treatment is a key goal of ST-elevation myocardial infarction (STEMI) emergency care. Emergency medical services (EMS) are a critical component of the STEMI chain of survival. Study Objective We sought to assess the impact of the careful integration of EMS as a strategy for improving systemic treatment times for STEMI. Methods We conducted a study of all 747 nontransfer STEMI patients who underwent primary percutaneous coronary intervention (PCI) in Dallas County, Texas from October 1, 2010 through December 31, 2011. EMS leaders from 24 agencies and 15 major PCI receiving hospitals collected and shared common, de-identified patient data. We used 15 months of data to develop a generalized linear regression to assess the impact of EMS on two treatment metrics—hospital door to balloon (D2B) time, and symptom onset to arterial reperfusion (SOAR) time, a new metric we developed to assess total treatment times. Results We found statistically significant reductions in median D2B (11.1-min reduction) and SOAR (63.5-min reduction) treatment times when EMS transported patients to the receiving facility, compared to self-transport. In addition, when trained EMS paramedics field-activated the cardiac catheterization laboratory using predefined specified protocols, D2B times were reduced by 38% (43 min) after controlling for confounding variables, and field activation was associated with a 21.9% reduction (73 min) in the mean SOAR time (both with p Conclusion Active EMS engagement in STEMI treatment was associated with significantly lower D2B and total coronary reperfusion times.

Post-resuscitation care of cardiac arrest patients at specialized centers may improve outcome after out-of-hospital cardiac arrest (OOHCA). This study describes experience with regionalized care of resuscitated patients.Los Angeles (LA) County established regionalized cardiac care in 2006. Since 2010, protocols mandate transport of nontraumatic OOHCA patients with field return of spontaneous circulation (ROSC) to a STEMI Receiving Center (SRC) with a hypothermia protocol. All SRC report outcomes to a registry maintained by the LA County Emergency Medical Services (EMS) Agency. We report the first year's data. The primary outcome was survival with good neurologic outcome, defined by a Cerebral Performance Category (CPC) score of 1 or 2.The SRC treated 927 patients from April 2011 through March 2012 with median age 67; 38% were female. There were 342 patients (37%) who survived to hospital discharge. CPC scores were unknown in 47 patients. Of the 880 patients with known CPC scores, 197 (22%) survived to hospital discharge with a CPC score of 1 or 2. The initial rhythm was VF/VT in 311 (34%) patients, of whom 275 (88%) were witnessed. For patients with an initial shockable rhythm, 183 (59%) survived to hospital discharge and 120 (41%) had survival with good neurologic outcome. Excluding patients who were alert or died in the ED, 165 (71%) patients with shockable rhythms received therapeutic hypothermia (TH), of whom 67 (42%) had survival with good neurologic outcome. Overall, 387 patients (42%) received TH. In the TH group, the adjusted OR for CPC 1 or 2 was 2.0 (95%CI 1.2-3.5, p = 0.01), compared with no TH. In contrast, the proportion of survival with good neurologic outcome in the City of LA in 2001 for all witnessed arrests (irrespective of field ROSC) with a shockable rhythm was 6%.We found higher rates of neurologically intact survival from OOHCA in our system after regionalization of post-resuscitation care as compared to historical data.

Reperfusion of ST elevation myocardial infarction (STEMI) is most effective when performed early. Notification of the cardiac catheterization laboratory (cath lab) prior to hospital arrival based on paramedic-performed ECGs has been proposed as a strategy to decrease time to reperfusion and mortality. The purpose of this study was to compare the effects of cath lab activation prior to patient arrival versus activation after arrival at the emergency department (ED).We performed a retrospective cohort study (n = 1933 cases) using Los Angeles County STEMI database from May 1, 2008 through August 31, 2009. The database includes patients arriving at a STEMI Receiving Center (SRC) by ambulance who were diagnosed with STEMI either before or after hospital arrival. We compared the cohort of patients with prehospital cath lab activation to those activated from the ED within 5 minutes of first ED ECG. Outcomes measured were mortality, door-to-balloon time, percent door-to-balloon time90 min, and percentage of false-positive activations.Prehospital cath lab activations had mean door-to-balloon times 14 minutes shorter (95% CI 11-17), in-hospital mortality 1.5% higher (95% CI -1.0-5.2), and false-positive activation 7.8%, (95% CI 2.7-13.3) higher than ED activation. For prehospital activation, 93% (95% CI 91-94%) met a door-to-balloon target of 90 minutes versus 85% (95% CI 80-88%) for ED activations.Prehospital cath lab activation based on the prehospital ECG was associated with decreased door-to-balloon times but did not affect hospital mortality. False-positive activation was common and occurred more often with prehospital STEMI diagnosis.

Evaluate treatment times and clinical outcome in a consecutive series of ST segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI) in Los Angeles County.Primary PCI for STEMI is beneficial if performed in a timely manner. Conflicting data exist regarding potential treatment delays for primary PCI performed during off hours.The Emergency Medical Services STEMI Receiving Center Database was queried from 2007 to 2009 to identify patients with a pre-hospital ECG showing STEMI who underwent PCI. On-hour PCI (On-hour Group, n = 1324) was defined as PCI occurring from 8 am to 5 pm and off-hour PCI (Off-hour Group, n = 922) was defined as occurring from 5 pm to 8 am. Treatment times, length of stay, vascular complications, achievement of TIMI 3 flow and in-hospital mortality were evaluated.Off-hours PCI occurred in 41% of patients. Medical contact to door time was similar in the Off-hour Group compared to the On-hour Group, 20.7 ± 14.6 versus 20.3 ± 12.3 min, respectively, P = 0.47. In patients with available data (n = 1366), the door-to-catheterization laboratory (CL) activation time was significantly shorter in the On-hour Group as compared to the Off-hour Group, -4.9 ± 11.9 versus -0.2 ± 27.5 min, respectively, P0.0001. Door-to-balloon time was significantly longer in the Off-hour Group compared to the On-hour Group, 74 ± 35 versus 60 ± 26 min respectively, P0.0001. Length of stay, vascular complications, final TIMI 3 flow and in-hospital mortality were similar between both groups.In STEMI patients receiving primary PCI in Los Angeles County, off-hour PCI was common. Short-term clinical outcomes were similar despite longer door-to-balloon time in patients receiving off-hour PCI. The longer door-to-balloon time in the off-hour PCI patients were partly explained by longer door-to-CL activation time.

The American Heart Association Caruth Initiative (AHACI) is a multiyear project to increase the speed of coronary reperfusion and create an integrated system of care for patients with ST-elevation myocardial infarction (STEMI) in Dallas County, TX. The purpose of this study was to determine if the AHACI improved key performance metrics, that is, door-to-balloon (D2B) and symptom-onset-to-balloon times, for nontransfer patients with STEMI.Hospital patient data were obtained through the National Cardiovascular Data Registry Action Registry-Get With The Guidelines, and prehospital data came from emergency medical services (EMS) agencies through their electronic Patient Care Record systems. Initial D2B and symptom-onset-to-balloon times for nontransfer primary percutaneous coronary intervention (PCI) STEMI care were explored using descriptive statistics, generalized linear models, and logistic regression.Data were collected by 15 PCI-capable Dallas hospitals and 24 EMS agencies. In the first 18 months, there were 3,853 cases of myocardial infarction, of which 926 (24%) were nontransfer patients with STEMI undergoing primary PCI. D2B time decreased significantly (P.001), from a median time of 74 to 64 minutes. Symptom-onset-to-balloon time decreased significantly (P.001), from a median time of 195 to 162 minutes.The AHACI has improved the system of STEMI care for one of the largest counties in the United States, and it demonstrates the benefits of integrating EMS and hospital data, implementing standardized training and protocols, and providing benchmarking data to hospitals and EMS agencies.

Objectives: To determine the causes of software misinterpretation of ST elevation myocardial infarction (STEMI) compared to clinically identified STEMI to identify opportunities to improve prehospital STEMI identification. Methods: We compared ECGs acquired from July 2011 through June 2012 using the LIFEPAK 15 on adult patients transported by the Los Angeles Fire Department. Cases included patients ≥18 years who received a prehospital ECG. Software interpretation of the ECG (STEMI or not) was compared with data in the regional EMS registry to classify the interpretation as true positive (TP), true negative (TN), false positive (FP), or false negative (FN). For cases where classification was not possible using registry data, 3 blinded cardiologists interpreted the ECG. Each discordance was subsequently reviewed to determine the likely cause of misclassification. The cardiologists independently reviewed a sample of these discordant ECGs and the causes of misclassification were updated in an iterative fashion. Results: Of 44,611 cases, 50% were male (median age 65; inter-quartile range 52–80). Cases were classified as 482 (1.1%) TP, 711 (1.6%) FP, 43371 (97.2%) TN, and 47 (0.11%) FN. Of the 711 classified as FP, 126 (18%) were considered appropriate for, though did not undergo, emergent coronary angiography, because the ECG showed definite (52 cases) or borderline (65 cases) ischemic ST elevation, a STEMI equivalent (5 cases) or ST-elevation due to vasospasm (4 cases). The sensitivity was 92.8% [95% CI 90.6, 94.7%] and the specificity 98.7% [95% CI 98.6, 98.8%]. The leading causes of FP were ECG artifact (20%), early repolarization (16%), probable pericarditis/myocarditis (13%), indeterminate (12%), left ventricular hypertrophy (8%), and right bundle branch block (5%). There were 18 additional reasons for FP interpretation (

Over the past 20 years, care for patients with ST-elevation myocardial infarction (STEMI) has rapidly evolved, not just in terms of how patients are treated, but where patients are treated. The advent of regional STEMI systems of care has decreased the number of "eligible but untreated" patients while improving access to primary percutaneous coronary intervention for patients. These regional STEMI systems of care have consistently demonstrated that rapid transport of STEMI patients is safe and effective, and have shown marked improvements in a variety of clinical outcomes. However, no two STEMI systems are alike, and each must be tailored to the unique geographic, political, and socioeconomic challenges of the region. This article takes an in-depth look at two of the earliest STEMI systems within the United States: the Minneapolis Heart Institute and the Los Angeles County STEMI receiving network.

Over the past two decades, Los Angeles County has implemented a Hospital Emergency Response Team (HERT) to provide on-scene, advanced surgical care of injured patients as an element of the local Emergency Medical Services (EMS) system. Since 2008, the primary responsibility of the team has been to perform surgical procedures in the austere field setting when prolonged extrication is anticipated. Following the maxim of “life over limb,” the team is equipped to provide rapid amputation of an entrapped extremity as well as other procedures and medical care, such as anxiolytics and advanced pain control. This report describes the development and implementation of a local EMS system HERT.Scott C, Putnam B, Bricker S, Schneider L, Raby S, Koenig W, Gausche-Hill M. The development and implementation of a Hospital Emergency Response Team (HERT) for out-of-hospital surgical care. Prehosp Disaster Med. 2012;27(3):1-5.

Objectives: The objective was to assess paramedic and emergency medical technicians (EMT) perspectives and decision-making after a policy change that allows forgoing or halting resuscitation in prehospital atraumatic cardiac arrest. Methods: Five semistructured focus groups were conducted with 34 paramedics and 2 EMTs from emergency medical services (EMS) agencies within Los Angeles County (LAC), 6 months after a policy change that allowed paramedics to forgo or halt resuscitation in the field under certain circumstances. Results: Participants had an overwhelmingly positive view of the policy; felt it empowered their decision-making abilities; and thought the benefits to patients, family, EMS, and the public outweighed the risks. Except under certain circumstances, such as when the body was in public view or when family members did not appear emotionally prepared to have the body left on scene, they felt the policy improved care. Assuming that certain patient characteristics were present, decisions by paramedics about implementing the policy in the field involve many factors, including knowledge and comfort with the new policy, family characteristics (e.g., agreement), and logistics regarding the place of arrest (e.g., size of space). Paramedic and EMT experiences with and attitudes toward forgoing resuscitation, as well as group dynamics among EMS leadership, providers, police, and ED staff, also play a role. Conclusions: Participants view the ability to forgo or halt resuscitation in the field as empowering and do not believe it presents harm to patients or families under most circumstances. Factors other than patient clinical characteristics, such as knowledge and attitudes toward the policy, family emotional preparedness, and location of arrest, affect whether paramedics will implement it. ACADEMIC EMERGENCY MEDICINE 2009; 16:532‐538 a 2009 by the Society for Academic Emergency Medicine

Objectives The aim of this study was to evaluate the rate of timely reperfusion for ST-elevation myocardial infarction (STEMI) with primary percutaneous coronary intervention (PPCI) in regional STEMI Receiving Center (SRC) networks. Background The American College of Cardiology Door-to-Balloon (D2B) Alliance target is a >75% rate of D2B ≤90 min. Independent initiatives nationwide have organized regional SRC networks that coordinate universal access to 9-1-1 with the pre-hospital electrocardiogram (PH-ECG) diagnosis of STEMI and immediate transport to a SRC (designated PPCI-capable hospital). Methods A pooled analysis of 10 independent, prospective, observational registries involving 72 hospitals was performed. Data were collected on all consecutive patients with a PH-ECG diagnosis of STEMI. The D2B and emergency medical services (EMS)-to-balloon (E2B) times were recorded. Results Paramedics transported 2,712 patients with a PH-ECG diagnosis of STEMI directly to the nearest SRC. A PPCI was performed in 2,053 patients (76%) with an 86% rate of D2B ≤90 min (95% confidence interval: 84.4% to 87.4%). Secondary analyses of this cohort demonstrated a 50% rate of D2B ≤60 min (n = 1,031), 25% rate of D2B ≤45 min (n = 517), and an 8% rate of D2B ≤30 min (n = 155). A tertiary analysis restricted to 762 of 2,053 (37%) cases demonstrated a 68% rate of E2B ≤90 min. Conclusions Ten independent regional SRC networks demonstrated a combined 86% rate of D2B ≤90 min, and each region individually surpassed the American College of Cardiology D2B Alliance benchmark. In areas with regional SRC networks, 9-1-1 provides entire communities with timely access to quality STEMI care.

Forgoing resuscitation in prehospital cardiac arrest has previously required a written prehospital do-not-resuscitate (DNR) order. Some emergency medical services (EMS) agencies, including Los Angeles County (LAC), have implemented policies allowing surrogate decision makers to verbally request to forgo resuscitation. The impact of a verbal DNR policy is unclear, given the absence of information about how often cardiac arrest occurs at home, or in the presence of a family member.To determine the prevalence of written DNR forms, rate of resuscitation, location of cardiac arrest, and availability of a family member in nontraumatic cardiac arrest prior to implementation of the new policy in LAC.All prehospital run sheets for nontraumatic cardiac arrest in LAC were reviewed for the first seven days of each month (August 2006-January 2007) for DNR status, location of cardiac arrest, presence of family members, and whether resuscitation was attempted.Of the 897 cardiac arrests, 492 occurred at home, 111 in a public place, and 93 in a nursing home (location was unknown for 201). Fifty-five patients (6%) had a written DNR order, although it was not always available. Of these 55 patients, ten were resuscitated, the majority of the time because the family could not produce the paperwork. A family member was listed as present 29% of the time (261 of 897 cases). A medical history was obtained in an additional 465 cases (52%), indicating that someone familiar with the patient's medical history was present more than half the time, even when a family member was not mentioned.A written DNR order is uncommonly used in the prehospital setting as a reason to forgo resuscitation in LAC. Even when family members state that the patient has a DNR order, patients are often resuscitated. A majority of cardiac arrests occurs at the patient's home, and in many cases in the presence of family members, some of whom may be able to express a patient's preferences regarding end-of-life care.

Old age is considered a negative prognostic factor after out-of-hospital cardiac arrest (OHCA). The purpose of this study was to assess the benefit of therapeutic hypothermia (TH) on survival and neurologic outcome in the elderly. This is a retrospective study of patients treated for OHCA from April 2011 to August 2013 in a regional cardiac system. Patients with return of spontaneous circulation (ROSC) are directed to designated cardiac receiving centers with established TH protocols. The decision to initiate TH is determined by the treating physician. All patients 65 years or older were identified. Patients were excluded if awake and responsive in the emergency department, died before hospital admission, or had preexisting coma. The adjusted odds ratio for survival with good neurologic outcome (defined as cerebral performance category [CPC] 1 or 2) was calculated for patients who received TH compared to a reference group without TH. There were 1612 patients, of whom 552 (34%) received TH. Median age was 78 (inter-quartile range [IQR] 71-85); 56% was male. 493 (31%) patients survived to hospital discharge, 266 (17%) with CPC of 1 or 2. Of 1292 patients considered for TH, 192 (25%) of 552 patients who received TH survived to hospital discharge and 97 (18%) with good neurologic outcome compared to 150 (20%) and 57 (8%), respectively, without TH. The adjusted odds ratio for survival with good neurologic outcome for TH was 2.0 (95% CI 1.3-3.3). TH is associated with improved neurologic outcome in the elderly population.

Background The effectiveness of out-of-hospital regionalization of ST-elevation myocardial infarction (STEMI) patients to hospitals providing primary percutaneous coronary intervention depends on the accuracy of the out-of-hospital 12-lead electrocardiogram (PHTL). Although estimates of sensitivity and specificity of PHTL for STEMI have been reported, the impact of out-of-hospital STEMI prevalence on positive predictive value (PPV) has not been evaluated. Objectives To describe the relationship between varying population STEMI prevalences and PHTL predictive values, using ranges of PHTL sensitivity and specificity. Methods The authors performed a Bayesian analysis using PHTL, where values for sensitivities (60%–70%), specificities (98%), and two prevalence ranges (0.5%–5% and 5%–20%) were derived from a literature review. PPV prediction intervals were compared with three months of prospective data from the Los Angeles County Emergency Medical Services Agency STEMI regionalization program. Results When the estimated prevalence of STEMI in the out-of-hospital population is 5%–20%, the median PPV of the PHTL is 83% (95% credible interval [CrI] = 53% to 97%). However, if the population prevalence of STEMI is between 0.5% and 5%, the median PPV is 43% (95% CrI = 12% to 86%). When the PPV prediction intervals were incorporated with the Los Angeles County Emergency Medical Services Agency data, the PPV was 66%. Conclusions Even when assuming high specificity for PHTL, the false-positive rate will be considerable if applied to a population at low risk for STEMI. Before broadening application of PHTL to low-risk patients, the implications of a high false-positive rate should be considered.

Recent studies document a high incidence of hyperventilation by prehospital providers, with a potentially detrimental effect on outcome in traumatic brain injury (TBI).To document the incidence of hyperventilation by aero-medical providers and explore a possible relationship between hyperventilation episodes and desaturations or impending hypoxemia.This was a prospective, descriptive study using TBI patients undergoing prehospital RSI by aero-medical crews. Continuous data regarding end-tidal CO2 (EtCO2), ventilatory rate, and oxygen saturation (SpO2) were downloaded from hand-held oximeter-capnometer devices. Two investigators independently assessed oximetry/capnometry data to identify the following occurrences: desaturation during RSI (SpO290%), impending hypoxemia (SpO2 decrease byor=3% to a value95%) following intubation, loss of SpO2 signal, hyperventilation (EtCO230 mm Hg), and severe hyperventilation (EtCO225 mm Hg). Covariate analysis was used to explore the possible association between hyperventilation episodes and either desaturation, impending hypoxemia, or loss of SpO2 signal.A total of 32 aero-medical patients were enrolled with a mean duration of ventilation monitoring of 14.8 min. The incidence of hyperventilation or severe hyperventilation was substantially lower than previously documented with ground paramedics. A total of 28 hyperventilation episodes were identified in 16 patients; 13 of these were associated with impending hypoxemia following intubation, five were associated with desaturation during RSI, and seven were associated with loss of SpO2 signal. The remaining three occurred immediately following intubation without desaturation during RSI. Desaturation was observed in 62% of patients; of note, desaturation was recorded on the quality improvement document in only 23% of these. Covariate analysis revealed an association between hyperventilation episodes and either desaturatios during RSI, impending hypoxemia following intubation, or loss of SpO2 signal.The incidence of hyperventilation by aeromedical crews was lower than reported for ground paramedics and appears to occur in response to desaturation, impending hypoxemia, or loss of SpO2 signal.

Introduction:Management of mass-casualty incidents should optimize outcomes by appropriate prehospital care, and patient triage to the most capably facilities. The number of patients, the nature of injuries, transportation needs, distances, and hospital capabilities and availabilities are all factors to be considered. Patient maldistributions such as overwhelming individual facilities, or transport to facilities incapable of providing appropriate care should be avoided. This report is a critical view of the application of the START triage nomenclature in the prehospital arena following a train crash in Los Angeles County on 26 January 2005.Methods:A scheduled debriefing was held with the major fire and emergency medical services responders, Medical Alert Center staff, and hospitals to assess and review the response to the incident. Site visits were made to all of the hospitals involved. Follow-up questions were directed to emergency department staff that were on duty during the day of the incident.Results:The five Level-I Trauma Centers responded to the poll with the capacity to receive a total of 12 “Immediate” patients, 2.4 patients per center, the eight Level-II Trauma Centers responded with capacity to receive 17 “Immediate” patients, two patients per center, while the 25 closest community hospitals offered to accept 75 “Immediate” patients, three patients per hospital. These community hospitals were typically about one-half of the size of the trauma centers (average 287 beds versus 548, average 8.7 operating rooms versus 16.6). Twenty-six patients were transported to a community hospital >15 miles from the scene, while eight closer community hospitals did not receive any patients.Conclusions:The debriefing summary of this incident concluded that there were no consistently used criteria to decide ultimate destination for “Immediates”, and that they were distributed about equally between community hospitals and trauma centers.

Airway management is one of the most important skills possessed by flight crews. However, few data exist about the efficacy of various educational approaches. Traditional models for airway training, including cadaver labs, operating room exposure, and clinical apprenticeships, are scarce and offer variable educational quality. The objective of this analysis was to evaluate the effectiveness of a simulator-based difficult airway curriculum in a large, aeromedical company.Simulation training was integrated into existing airway training for all crew members; an original difficult airway algorithm was used to guide scenarios. To evaluate its effectiveness, rapid sequence intubation (RSI) success before and after curriculum implementation was determined. In addition, crew members rated their confidence with various aspects of airway management before and after exposure to the airway workshops.First attempt and overall ETI success improved from 71.3% and 89.3% before (n=261) to 87.5% and 94.6% after (n=504) implementation of the algorithm and simulation training, whereas the incidence of hypoxic arrests during RSI decreased from 2.7% to 0.2% (p0.01 for all comparisons). Crew members reported improvements in confidence with regard to all aspects of airway management following participation in the simulation workshops.A novel, integrated airway management curriculum using treatment algorithms and simulation appeared to be effective for improving RSI success among air medical crews in this program.

Therapeutic hypothermia (TH) improves neurologic outcome in patients resuscitated from ventricular fibrillation. The purpose of this study was to evaluate TH effects on neurologic outcome in patients resuscitated from a non-shockable out-of-hospital cardiac arrest rhythm. This is a retrospective cohort study of data reported to a registry in an emergency medical system in a large metropolitan region. Patients achieving field return of spontaneous circulation are transported to designated hospitals with TH protocols. Patients with an initial non-shockable rhythm were identified. Patients were excluded if awake in the Emergency Department or if TH was withheld due to preexisting coma or death prior to initiation. The decision to initiate TH was determined by the treating physician. The primary outcome was survival with good neurologic outcome defined by a cerebral performance category of 1 or 2. Of the 2772 patients treated for cardiac arrest during the study period, there were 1713 patients resuscitated from cardiac arrest with an initial non-shockable rhythm and 1432 patients met inclusion criteria. The median age was 69 years [IQR 59–82]; 802 (56 %) male. TH was induced in 596 (42 %) patients. Survival with good neurologic outcome was 14 % in the group receiving TH, compared with 5 % in those not treated with TH (risk difference = 8 %, 95 % CI 5–12 %). The adjusted OR for a CPC 1 or 2 with TH was 2.9 (95 % CI 1.9–4.4). Analyzing the data collected from the registry of the standard practice in a large metropolitan region, TH is associated with improved neurologic outcome in patients resuscitated from initial non-shockable rhythms in a regionalized system for post-resuscitation care.

Recent developments have provided a unique opportunity for the organization of regional ST-elevation myocardial infarction (STEMI) receiving center (SRC) networks. Because cumulative evidence has demonstrated that rapid primary percutaneous coronary intervention (PCI) is the most effective reperfusion strategy for acute STEMI, the development of integrated SRC networks could extend the benefits of primary PCI to a much larger segment of the US population. Factors that favor the development of regional SRC networks include results from recently published clinical trials, insight into contemporary STEMI treatment patterns from observational registries, experience with the nation's current trauma system, and technological advances. In addition, the 2004 American College of Cardiology/American Heart Association STEMI guidelines have specified that optimal "first medical contact-to-balloon" times should be

Oxygen is one of the most frequently-used therapeutic agents in medicine and the most commonly administered drug by prehospital personnel. There is increasing evidence of harm with too much supplemental oxygen in certain conditions, including stroke, chronic obstructive pulmonary disease (COPD), neonatal resuscitations, and in postresuscitation care. Recent guidelines published by the British Thoracic Society (BTS) advocate titrated oxygen therapy, but these guidelines have not been widely adapted in the out-of-hospital setting where high-flow oxygen is the standard. This report is a description of the implementation of a titrated oxygen protocol in a large urban-suburban Emergency Medical Services (EMS) system and a discussion of the practical application of this out-of-hospital protocol.BossonN,Gausche-HillM,KoenigW.Implementation of a titrated oxygen protocol in the out-of-hospital setting.Prehosp Disaster Med.2014;28(4):1-6.

Primary percutaneous coronary intervention (PPCI) is the preferred method of reperfusion for ST-segment elevation myocardial infarction (STEMI), if it can be performed in a timely manner by an experienced interventional cardiologist at a high volume STEMI Receiving Center. However, an estimated 50% of STEMI patients present to STEMI Referral Centers without PPCI capability. Transfer of STEMI patients for PPCI has been shown to improve outcomes as compared with fibrinolysis given at the presenting hospital. Nonetheless, transfer of STEMI patients for PPCI has not been used extensively in the United States and is associated with markedly prolonged transfer times. This study demonstrates that rapid transfer of STEMI patients from community hospitals without PPCI capability to a STEMI Receiving Center is both safe and feasible using a standardized protocol with an integrated transfer system.

Background: Stroke systems of care include routing patients to the nearest designated stroke center hospital, bypassing non-designated hospitals. Routing protocols are implemented at the state or county level and vary in qualification criteria and determination of destination hospital. We surveyed all counties in the state of California for presence and characteristics of their prehospital stroke routing protocols. Methods: Each county in California was queried for the presence of a stroke routing protocol. These protocols were obtained and reviewed for method of stroke identification and criteria for patient transport to a stroke center. Results: Thirty-three local EMS agencies (LEMSAs) serve 58 counties in California with populations ranging from 1175 to almost 10 million (mean 642,000), area ranging from 47 to 20,000 sq. mi (mean 2690) and population density 2 to 17,000 persons per sq. mi (mean 661). Fifteen LEMSAs (45%) had stroke routing protocols, covering 23 counties (40%) and 68% of the state population. Counties with protocols had higher population density (1500 vs. 140 persons per sq. mi). All protocols designated a time period from symptom onset to EMS evaluation to qualify for routing, median 3 hr (IQR 2.5-4, range 2 - 8). Twelve of 23 (52%) allowed a maximum transport time of 30 minutes to qualify for diversion. The number of LEMSA-designated stroke hospitals per county in jurisdictions with diversion was median 2 (IQR 0-7, range 0 - 29). In the six counties without designated stroke centers, patients meeting criteria were transported out of county. Stroke identification in the field among diverting LEMSAs was achieved using the CPSS/FAST in 23, the LAPSS in 2, county-specific protocol in 7, and not stated in 1. Conclusion: California EMS stroke routing protocols cover 68% of the state population and vary in characteristics including activation by symptom onset time and destination facility features, reflecting matching of system design to local geographic resources.

a b s t r a c t Background: Dismal prognosis after failed out-of-hospital resuscitation has previously been demon- strated. Changes in resuscitation and post-resuscitation care may affect patient outcomes. We describe characteristics and outcomes of patients with out-of-hospital cardiac arrest (OOHCA) transported to specialty cardiac centers after failure of out-of-hospital interventions. Methods: In Los Angeles (LA) County, patients with non-traumatic OOHCA with return of spontaneous circulation (ROSC) are transported to specialized cardiac care centers. Outcomes are reported to a registry maintained by the LA County Emergency Medical Services (EMS) Agency. We report patient character- istics and outcomes for the subset of patients treated at these specialty centers in whom initial ROSC was achieved in the ED. The primary outcome was neurologically intact survival, defined by a cerebral performance category (CPC) score of 1 or 2. Results: 105 patients transported to the SRC after failure to achieve ROSC with out-of-hospital resus- citation were successfully resuscitated in the ED. The median age was 68 years (IQR 57-78); 74 (70%) were male. The presenting rhythm was ventricular fibrillation or ventricular tachycardia in 40 patients (38%) and 86 (82%) were witnessed. Twenty-two patients (21%) survived to hospital discharge. Of the 103 patients with known CPC scores, 13 (13% (95% CI 7-21%)) survived to hospital discharge with a CPC score of 1 or 2. No patient who survived with good neurologic outcome met criteria for termination of resuscitation in the field. Conclusion: Failure of out-of-hospital resuscitation is not universally predictive of poor neurologic out- come.

BACKGROUND : The purpose of this study was to determine whether imbrication of native fascia versus excision and closure of new raw fascia forms a stronger union. METHODS : We utilized the anterior rectus sheath fascia of Sprague-Dawley rats as the model. Sixty rats underwent fascial tightening procedures. Each rat had the anterior rectus sheath shortened by 1 cm, 30 by imbrication and 30 by excision and closure. Ten of each group were harvested at 7 days' healing, 10 at 14 days, and 10 of each group at 28 days' healing. The anterior rectus sheath was removed, a dumbbell shape constructed, and the cross sectional area at the point of interest determined. The fascia was placed on an Instron tensiometer to determine the breaking strength. Tensile strength was calculated and the data analyzed by ANOVA and the Kruskall-Wallis test. Tissue samples of the closures were histologically analyzed for fibroblast counts, degree of inflammation, and presence of dense fibrous connective tissue. Tissue samples were also analyzed for enzymatic collagen crosslinking. RESULTS : There was a statistically significant difference in tensile strength between the two groups at 7, 14, and 28 days. Results show that at 7 days the mean tensile strength of excision was 0.133 kg/mm 2 ± 0.056 and the mean tensile strength of imbrication was 0.083 kg/mm 2 ±.048 (P

To describe current prehospital airway management practices for adults and children and barriers to adoption of evidence-based airway management practices in California.We surveyed local medical directors of California's 31 emergency medical services (EMS) agencies regarding prehospital airway management, including provider scope of practice, continuous quality improvement practices, and perceptions regarding barriers to the implementation of evidence-based airway management practices. The survey instrument was a Web-based, closed-response form ( www.surveymonkey.com ) that medical directors could access by an e-mailed link provided by investigators. Medical directors were contacted by phone, mail, and e-mail to request their participation in the Web-based survey.Twenty-five of 31 (81%) EMS medical directors completed the survey. Five medical directors completed surveys for two agencies over which they had responsibility. All responding medical directors employ bag-mask ventilation (BMV), airway adjuncts, and adult endotracheal intubation (ETI), which are procedures widely accepted in EMS practice. Rapid-sequence intubation (RSI), which has been shown to cause harm in certain patient subgroups, was not employed by any of the respondents. Prehospital pediatric ETI, which has been shown not to provide any benefit over BMV, was employed by 22 of 25 (88%) medical directors. Thirteen of 23 (57%) respondents identified "more evidence is needed" or "these results do not apply to my EMS system" as the top reasons to continue the practice of prehospital pediatric ETI.The results of our study suggest that in areas of EMS where robust evidence exists, medical directors (100%) will discontinue or not adopt skills that potentially harm patients, such as RSI, but are unlikely (12%) to discontinue procedures that show no benefit to patients (such as pediatric ETI). Barriers to adoption of evidence-based practice include difficulty in generalizing results of studies across diverse EMS systems and perceived lack of evidence that the procedure should be abandoned.

Despite potential harm to patients, families, and emergency personnel, a low survival rate, and high costs and intensity of care, attempting resuscitation after prehospital cardiac arrest is the norm, unless there are signs of irreversible death or the presence of a valid, state-issued DNR.To determine whether there was a change in the rate of forgoing resuscitation attempts in prehospital cardiac arrest after implementation of a new policy allowing paramedics to forgo resuscitation based on a verbal family request or the presence of certain arrest characteristics.All prehospital run sheets for cardiac arrest in Los Angeles County were reviewed for the first seven days of each month August 2006-January 2007 (pre-policy) and January-June 2008 (post-policy). Paramedics were more likely to forgo resuscitation attempts after the policy change (13.3% vs. 8.5%, p0.01). In addition, the percentage of patients with documented signs of irreversible death decreased post-policy, from 50.4% to 35.8%, p0.01. After adjustment for potential confounders (patient demographics, clinical characteristics and EMS factors), as well as exclusion of patients with signs of irreversible death, paramedics are significantly more likely to forgo a resuscitation, and less likely to attempt resuscitation, after the policy change (OR 1.67 [95% CI 1.07, 2.61], p=0.024).Paramedics are more likely to forgo, and less likely to attempt, resuscitation in victims of cardiac arrest after implementation of a new policy. There was also an associated decrease in the percentage of patients who had signs of irreversible death, which might reflect a change in paramedic behavior.

Early percutaneous coronary intervention (PCI) has been shown to be superior to fibrinolytic therapy and is associated with reduced morbidity and mortality for patients with ST-segment elevation myocardial infarction (STEMI).To determine the performance of a regional system with prehospital 12-lead electrocardiogram (ECG) identification of STEMI patients and direct paramedic transport to STEMI receiving centers (SRCs) for provision of primary PCI.This was a prospective study evaluating the first year of implementation of a regional SRC network to determine the key time intervals for patients identified with STEMI in the prehospital setting. Results. During the 12-month study period, 1,220 patients with a suspected STEMI were identified on prehospital 12-lead ECG, of whom 734 (60%) underwent emergency PCI. A door-to-balloon time of 90 minutes or less was achieved for 651 (89%) patients, and 459 (62.5%) had EMS-patient contact-to-balloon timesor= 90 minutes. Transport of suspected STEMI patients to an SRC resulted in ambulance diversion from a closer ED for 31% of patients and a median increase in transport time of 3.8 minutes.Door-to-balloon times within the 90-minute benchmark were achieved for almost 90% of STEMI patients transported by paramedics after implementing our regionalized SRC system.

The vast majority of out-of-hospital cardiac arrest victims do not survive or suffer severe neurological impairment. We sought to develop a set of straightforward clinical indicators that paramedics could use to better match resuscitation attempts to those most likely to benefit.In partnership with the Los Angeles County Emergency Medical Services, we used the RAND/UCLA appropriateness method of quantifying expert opinion regarding the risks and benefits of medical procedures. We presented available scientific evidence related to potential indicators of the quality of resuscitative care to stakeholder-nominated experts. Forty-one candidate indicators incorporated key variables, including initial rhythm, patient preferences, presence of witnesses, and place of arrest. Nine panelists, including palliative care and emergency medical specialists, rated the appropriateness of paramedic use of each indicator by using a 1-9 scale. An indicator was considered appropriate if the potential benefits outweighed the potential harm to the patient or their family. Indicators were retained if median score was/=7.The expert panel voted to retain 28 quality indicators. Three addressed signs of irreversible death (e.g., dependent lividity), 8 addressed patient preferences (e.g., inquiring about DNR status), and the remainder addressed combinations of initial rhythm and other prognostic signs (e.g., "If initial rhythm is asystole and patient is known by apparent surrogate decision maker to have a terminal illness, then forgo resuscitation."). Our experts recommended a series of much more liberal criteria for forgoing resuscitation than is currently practiced. This includes ascertaining and honoring patient preferences, either through written documents or family members, and combinations of clinical criteria that predict poor neurological outcome, such as asystole, terminal illness, age greater than 70, and response time greater than 15 minutes.These quality indicators expand on the previously limited circumstances in which paramedics might forgo field resuscitation and implementation could reduce future harm from such procedures among seriously ill patients. Our current efforts focus on using these indicators to aid implementation of a new resuscitation policy for seriously ill patients in our county.

OBJECTIVE. The goal was to describe the change in the rate of epinephrine dosing errors in the treatment of pediatric patients in prehospital cardiopulmonary arrest after the Los Angeles County Emergency Medical Services Agency instituted a program in which paramedics were required to use the Broselow tape and to report color zone categories to the base station and base stations were given and instructed formally in the use of the color-coded drug dosing chart. METHODS. An observational analysis of a natural experiment was performed. Children ≤12 years of age who were determined to be in prehospital cardiopulmonary arrest and who received prehospital epinephrine treatment by paramedics, in the periods of 1994 to 1997 and 2003 to 2004, were included in the study. RESULTS. In the 1994 to 1997 cohort, we identified 104 subjects in prehospital cardiopulmonary arrest who received epinephrine with a documented weight and route of administration. Only 29 of 104 subjects in the 1994 to 1997 cohort received the correct dose, whereas 46 of 104 subjects received a first dose within 20% of the correct dose. In the 2003 to 2004 cohort, we identified 41 children ≤12 years of age who were in cardiopulmonary arrest and received prehospital epinephrine treatment but 4 children were excluded, leaving 37 subjects. Twenty-one of 37 subjects received the correct dose, whereas 24 of 37 subjects received a dose within 20%. The odds ratio for obtaining the correct epinephrine dose after the system changes versus before was 3.0, and that for obtaining a dose within 20% of the correct dose was 2.5. CONCLUSIONS. The program seems to have resulted in reduction of the rate of epinephrine dosing errors in the prehospital treatment of children in cardiopulmonary arrest in Los Angeles County.

Study objective We assess the effects of nearby hospital closures and other hospital characteristics on emergency department (ED) ambulance diversion. Methods The study design was a retrospective, multiple interrupted time series with control group. We studied all ambulance-receiving hospitals with EDs in Los Angeles County from 1998 to 2004. The main outcome measure was monthly ambulance diversion hours because of ED saturation. Results Our sample included 80 hospitals, of which 9 closed during the study period. There were increasing monthly diversion hours over time, from an average of 57 hours (95% confidence interval [CI] 51 to 63 hours) in 1998 to 190 hours (95% CI 180 to 200 hours) in 2004. In multivariate modeling, hospital closure increased ambulance monthly diversion hours by an average of 56 hours (95% CI 28 to 84 hours) for 4 months at the nearest ED. County-operated hospitals had 150 hours (95% CI 90 to 200 hours) and trauma centers had 48 hours (95% CI 9 to 87 hours) more diversion than other hospitals. Diversion hours for a given facility were positively correlated with diversion hours of the nearest ED (0.3; 95% CI 0.28 to 0.32). There was a significant and positive interaction between diversion hours of the nearest ED and time, suggesting that the effects of an adjacent facility's diversion hours increased during the study period. Conclusion Hospital closure was associated with a significant but transient increase in ambulance diversion for the nearest ED. The temporal trend toward more diversion hours, as well as increasing effects of the nearest facility's diversion hours over time, implies that the capacity to absorb future hospital closures is declining.

Inter-facility transfer (IFT) for primary PCI for STEMI presents multiple logistic challenges. Recent data from ACC/AHA ACTION Registry of approximately 300 hospitals within the United States found that fewer than 20% of IFT patients achieved a door to balloon time < 90 minutes. The objective of

The field identification of the patients who should be taken to trauma centers is a major problem of trauma care. This study appears to be the first to use multivariate analysis to systematically design a field triage instrument and to evaluate its performance in terms of a meaningful and plausible criterion for which patients ought to be treated at trauma centers. Four new triage instruments were created and their performance compared to that of two existing measures, the Trauma Score and the CRAMS scale. The new measures appear to perform better than the best of existing instruments tested, although independent validation is necessary. The one purely physiologic instrument tested appeared to be inferior to instruments that included anatomic and historic as well as physiologic indices. Simple checklists performed approximately as well as weighted scales. No instrument was found to be high in both sensitivity and positive accuracy.

Summary Strain UMK-13 of the achlorophyllous alga Prototheca zopfii Kruger was tested for itsability to grow on crude-oil under a variety of conditions of pH, temperature, and salinity representing various aquatic habitats. Biodegradation of 13-16 carbon and 20-21 carbon n-alkanes occurred within a pH range of 3-9, at 8-24 parts per thousand salinity, and at 15-25 °C; no growth or biodegradation occurred at 30 °C or above. During 25 days of growth under favorable conditions strain UMK-13 removed up to 40 of the crude-oil n-alkanes assayed. The data indicate that Prototheca zopfii strain UMK-13 can contribute to crude-oil biodegradation in a variety of estuarine and freshwater habitats.