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Desai S, Remick KE. Overcoming Vulnerabilities in Our Emergency Care System Through Pediatric Readiness. Pediatr Clin North Am 2024; 71:371-381. [PMID: 38754930 DOI: 10.1016/j.pcl.2024.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/18/2024]
Abstract
Although children account for 20% of all emergency department (ED) visits, the majority of children seek emergency care in hospitals that see fewer than 10 children per day. The National Pediatric Readiness Project has defined key system-level standards for all EDs to safely care for ill and injured children. High pediatric readiness is associated with improvement in mortality for critically ill and injured children. However, to improve readiness and sustain system-level changes, hospitals must invest in pediatric champions and empower them to engage in continuous quality improvement. Finally, incorporating pediatric readiness into policy is crucial for its long-term sustainability.
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Affiliation(s)
- Sanyukta Desai
- Department of Pediatrics, Dell Medical School, University of Texas at Austin, Austin, TX 78723, USA
| | - Katherine E Remick
- Department of Pediatrics, Dell Medical School, University of Texas at Austin, Austin, TX 78723, USA.
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2
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Brunson DC, Miller KA, Matheson LW, Carrillo E. Race and Ethnicity and Prehospital Use of Opioid or Ketamine Analgesia in Acute Traumatic Injury. JAMA Netw Open 2023; 6:e2338070. [PMID: 37847499 PMCID: PMC10582796 DOI: 10.1001/jamanetworkopen.2023.38070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 09/05/2023] [Indexed: 10/18/2023] Open
Abstract
Importance Racial and ethnic disparities in pain management have been characterized in many hospital-based settings. Painful traumatic injuries are a common reason for 911 activations of the EMS (emergency medical services) system. Objective To evaluate whether, among patients treated by EMS with traumatic injuries, race and ethnicity are associated with either disparate recording of pain scores or disparate administration of analgesia when a high pain score is recorded. Design, Settings, and Participants This cohort study included interactions from 2019 to 2021 for US patients ages 14 to 99 years who had experienced painful acute traumatic injuries and were treated and transported by an advanced life support unit following the activation of the 911 EMS system. The data were analyzed in January 2023. Exposures Acute painful traumatic injuries including burns. Main Outcomes and Measures Outcomes were the recording of a pain score and the administration of a nonoral opioid or ketamine. Results The study cohort included 4 781 396 EMS activations for acute traumatic injury, with a median (IQR) patient age of 59 (35-78) years (2 497 053 female [52.2%]; 31 266 American Indian or Alaskan Native [0.7%]; 59 713 Asian [1.2%]; 742 931 Black [15.5%], 411 934 Hispanic or Latino [8.6%], 10 747 Native Hawaiian or other Pacific Islander [0.2%]; 2 764 499 White [57.8%]; 16 161 multiple races [0.3%]). The analysis showed that race and ethnicity was associated with the likelihood of having a pain score recorded. Compared with White patients, American Indian and Alaskan Native patients had the lowest adjusted odds ratio (AOR) of having a pain score recorded (AOR, 0.74; 95% CI, 0.71-0.76). Among patients for whom a high pain score was recorded (between 7 and 10 out of 10), Black patients were about half as likely to receive opioid or ketamine analgesia as White patients (AOR, 0.53; 95% CI, 0.52-0.54) despite having a pain score recorded almost as frequently as White patients. Conclusions and Relevance In this nationwide study of patients treated by EMS for acute traumatic injuries, patients from racial or ethnic minority groups were less likely to have a pain score recorded, with Native American and Alaskan Natives the least likely to have a pain score recorded. Among patients with a high pain score, patients from racial and ethnic minority groups were also significantly less likely to receive opioid or ketamine analgesia treatment, with Black patients having the lowest adjusted odds of receiving these treatments.
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Affiliation(s)
- Dalton C. Brunson
- School of Medicine, Stanford University School of Medicine, Stanford, California
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, California
| | - Kate A. Miller
- Quantitative Sciences Unit, Stanford University School of Medicine, Stanford University, Stanford, California
| | - Loretta W. Matheson
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, California
| | - Eli Carrillo
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, California
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3
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Li T, Koloden D, Berkowitz J, Luo D, Luan H, Gilley C, Kurgansky G, Barbara P. Prehospital transport and termination of resuscitation of cardiac arrest patients: A review of prehospital care protocols in the United States. Resusc Plus 2023; 14:100397. [PMID: 37252026 PMCID: PMC10213088 DOI: 10.1016/j.resplu.2023.100397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 04/26/2023] [Accepted: 04/29/2023] [Indexed: 05/31/2023] Open
Abstract
Background The objective was to describe emergency medical services (EMS) protocol variability in transport expectations for out-of-hospital cardiac arrest (OHCA) patients and the involvement of online medical control for on-scene termination of resuscitation in the United States. Whether other aspects of OHCA care were mentioned, including the definition of a "pediatric" patient, and use of end-tidal carbon dioxide monitoring, mechanical chest compression devices (MCCDs), and extracorporeal membrane oxygenation (ECMO), were also described. Methods and Results Review of EMS protocols publicly accessible from https://www.emsprotocols.org and through searches on the internet when protocols were unavailable on the website from June 2021 to January 2022. Frequencies and proportions were used to describe outcomes. Of 104 protocols reviewed, 51.9% state to initiate transport after return of spontaneous circulation (ROSC), 26.0% do not specify when to initiate transport, and 6.7% state to transport after ≥20 minutes of on-scene cardiopulmonary resuscitation for adults. For pediatric patients, 38.5% of protocols do not specify when to initiate transport, 32.7% state to transport after ROSC, and 10.6% state to transport as soon as possible. Most protocols (42.3%) did not specify the age that defines "pediatric" in cardiac arrest. More than half (51.9%) of the protocols require online medical control for termination of resuscitation. Most protocols mention the use of end-tidal carbon dioxide monitoring (81.7%), 50.0% mention the use of MCCDs, and 4.8% mention ECMO for cardiac arrest. Conclusions In the United States, EMS protocols for initiation of transport and termination of resuscitation for OHCA patients are highly variable.
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Affiliation(s)
- Timmy Li
- Department of Emergency Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 300 Community Drive, Manhasset, NY, USA
| | - Daniel Koloden
- Center for Emergency Medical Services, Northwell Health, 15 Burke Lane, Syosset, NY, USA
| | - Jonathan Berkowitz
- Department of Emergency Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 300 Community Drive, Manhasset, NY, USA
- Center for Emergency Medical Services, Northwell Health, 15 Burke Lane, Syosset, NY, USA
| | - Dee Luo
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 500 Hofstra Blvd, Hempstead, NY, USA
| | - Howard Luan
- Feinstein Institutes for Medical Research, Northwell Health, 350 Community Drive, Manhasset, NY, USA
| | - Charles Gilley
- Feinstein Institutes for Medical Research, Northwell Health, 350 Community Drive, Manhasset, NY, USA
| | - Gregory Kurgansky
- Feinstein Institutes for Medical Research, Northwell Health, 350 Community Drive, Manhasset, NY, USA
| | - Paul Barbara
- Department of Emergency Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 300 Community Drive, Manhasset, NY, USA
- Center for Emergency Medical Services, Northwell Health, 15 Burke Lane, Syosset, NY, USA
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Farhat H, Alinier G, El Aifa K, Athemneh K, Gangaram P, Romero R, Khenissi MC, Al Shaikh L, Laughton J. Quality improvement tools to manage emergency callbacks from patients with diabetes in a prehospital setting. BMJ Open Qual 2023; 12:bmjoq-2022-002007. [PMID: 36599502 DOI: 10.1136/bmjoq-2022-002007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 12/23/2022] [Indexed: 01/06/2023] Open
Abstract
Diabetes is rising at an alarming rate, as 1 in 10 adults worldwide now lives with the disease. In Qatar, a middle eastern Arab country, diabetes prevalence is equally concerning and is predicted to increase from 17% to 24% among individuals aged 45 and 54 years by 2050. While most healthcare strategies focus on preventative and improvement of in-hospital care of patients with diabetes, a notable paucity exists concerning diabetes in the prehospital setting should ideally be provided. This quality improvement study was conducted in a middle eastern ambulance service and aimed to reduce ambulance callbacks of patients with diabetes-related emergencies after refusing transport to the hospital at the first time. We used iterative four-stage problem-solving models. It focused on the education and training of both paramedics and patients. The study showed that while it was possible to reduce the rate of ambulance callbacks of patients with diabetes, this was short-lived and numbers increased again. The study demonstrated that improvements could be effective. Hence, changes that impacted policy, systems of care and ambulance protocols directed at managing and caring for patients with diabetes-related prehospital emergencies may be required to reify them.
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Affiliation(s)
- Hassan Farhat
- Ambulance Service, Hamad Medical Corporation, Doha, Qatar .,Faculty of Medicine, University of Sousse, Sousse, Tunisia.,Faculty of Sciences, University of Sfax, Sfax, Tunisia
| | - Guillaume Alinier
- Ambulance Service, Hamad Medical Corporation, Doha, Qatar.,University of Hertfordshire Faculty of Health and Human Sciences, Hatfield, UK.,Weill Cornell Medicine-Qatar, Doha, Qatar.,Northumbria University, Newcastle upon Tyne, UK
| | | | - Khawla Athemneh
- Hamad Healthcare Quality Institute, Hamad Medical Corporation, Doha, Qatar
| | - Padarath Gangaram
- Ambulance Service, Hamad Medical Corporation, Doha, Qatar.,Durban University of Technology, Durban, KwaZulu-Natal, South Africa
| | - Ricardo Romero
- Ambulance Service, Hamad Medical Corporation, Doha, Qatar
| | | | - Loua Al Shaikh
- Ambulance Service, Hamad Medical Corporation, Doha, Qatar
| | - James Laughton
- Ambulance Service, Hamad Medical Corporation, Doha, Qatar
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Sinclair JE, Austin MA, Leduc S, Dionne R, Froats M, Marchand J, Vaillancourt C. Patient and Prehospital Predictors of Hospital Admission for Patients With and Without Histories of Diabetes Treated by Paramedics for Hypoglycemia: A Health Record Review Study. PREHOSP EMERG CARE 2022; 27:955-966. [PMID: 36264569 DOI: 10.1080/10903127.2022.2137863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 09/29/2022] [Accepted: 10/15/2022] [Indexed: 10/24/2022]
Abstract
OBJECTIVES The objectives of this study were to describe the characteristics, management, and outcomes of patients treated by paramedics for hypoglycemia, and to determine the predictors of hospital admission for these patients within 72 hours of the initial hypoglycemia event. METHODS We performed a health record review of paramedic call reports and emergency department records over a 12-month period. We queried prehospital databases to identify cases, which included all patients ⩾18 years with prehospital glucose readings of <72 mg/dl (<4.0 mmol/L) and excluded terminally ill and cardiac arrest patients. We developed and piloted a standardized data collection tool and obtained consensus on all data definitions before initiation of data extraction by trained investigators. Data analyses included descriptive statistics univariate and logistic regression presented as adjusted odds ratios (aOR) with 95% confidence intervals (95%CI). RESULTS There were 791 patients with the following characteristics: mean age 56.2, male 52.3%, type 1 diabetes 11.6%, on insulin 43.3%, median initial glucose 54.0 mg/dl (3.0 mmol/L), from home 56.4%. They were treated by advanced care paramedics 80.1%, received intravenous D50 37.8%, intramuscular glucagon 17.8%, oral complex carbs/protein 25.7%, and accepted transport to hospital 70.2%. Among those transported, 134 (24.3%) were initially admitted and four more were admitted within 72 hours. One patient was admitted, discharged, and admitted again within 72 hours. Patients without documented histories of diabetes (aOR 2.35, CI 1.13-4.86), with cardiovascular disease (aOR 1.81, CI 1.10-3.00), on corticosteroids (aOR 4.63, CI 2.15-9.96), on oral hypoglycemic agent(s) (aOR 1.92, CI 1.02-3.62), or those given glucagon (aOR 1.77, CI 1.07-2.93) on scene were more likely to be admitted to hospital, whereas patients on insulin (aOR 0.49, CI 0.27-0.91), able to tolerate complex oral carbs/protein (aOR 0.22, CI 0.10-0.48), with final GCS scores of 15 (aOR 0.53, CI 0.34-0.83), or from public locations (aOR 0.40, CI 0.21-0.75) were less likely to be admitted. CONCLUSIONS There are several patient and prehospital management characteristics which, in combination, could be incorporated into a safe clinical decision tool for patients who present with hypoglycemia.
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Affiliation(s)
| | - Michael A Austin
- Regional Paramedic Program for Eastern Ontario, Ottawa, Ontario
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario
- Ottawa Hospital Research Institute, Ottawa, Ontario
| | - Shannon Leduc
- Ottawa Hospital Research Institute, Ottawa, Ontario
- Ottawa Paramedic Service, Ottawa, Ontario
| | - Richard Dionne
- Regional Paramedic Program for Eastern Ontario, Ottawa, Ontario
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario
| | - Mark Froats
- Regional Paramedic Program for Eastern Ontario, Ottawa, Ontario
- Department of Emergency Medicine, Queen's University, Kingston, Ontario
| | - Jane Marchand
- Regional Paramedic Program for Eastern Ontario, Ottawa, Ontario
| | - Christian Vaillancourt
- Regional Paramedic Program for Eastern Ontario, Ottawa, Ontario
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario
- Ottawa Hospital Research Institute, Ottawa, Ontario
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Myers LA, Swanson KM, Glasgow AE, McCoy RG. Management and Outcomes of Severe Hypoglycemia Treated by Emergency Medical Services in the U.S. Upper Midwest. Diabetes Care 2022; 45:1788-1798. [PMID: 35724305 PMCID: PMC9346993 DOI: 10.2337/dc21-1811] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Accepted: 05/03/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To examine factors associated with emergency department (ED) transport after hypoglycemia treated by emergency medical services (EMS) and assess the impact of ED transport on severe hypoglycemia recurrence. RESEARCH DESIGN AND METHODS We retrospectively analyzed electronic health records of a multistate advanced life support EMS provider and an integrated healthcare delivery system serving an overlapping geographic area in the upper Midwest. For adults with diabetes treated by EMS for hypoglycemia between 2013 and 2019, we examined rates of ED transport, factors associated with it, and its impact on rates of recurrent hypoglycemia requiring EMS, ED, or hospital care within 3, 7, and 30 days. RESULTS We identified 1,977 hypoglycemia-related EMS encounters among 1,028 adults with diabetes (mean age 63.5 years [SD 17.7], 55.2% male, 87.4% non-Hispanic White, 42.4% rural residents, and 25.6% with type 1 diabetes), of which 46.4% resulted in ED transport (31.1% of calls by patients with type 1 diabetes and 58.0% of calls by patients with type 2 diabetes). Odds of ED transport were lower in patients with type 1 diabetes (odds ratio [OR] 0.44 [95% CI 0.31-0.62] vs. type 2 diabetes) and higher in patients with prior ED visits (OR 1.38 [95% CI 1.03-1.85]). Within 3, 7, and 30 days, transported patients experienced recurrent severe hypoglycemia 2.8, 5.2, and 10.6% of the time, respectively, compared with 7.4, 11.2, and 22.8% of the time among nontransported patients (all P < 0.001). This corresponds to OR 0.58 (95% CI 0.42-0.80) for recurrent severe hypoglycemia within 30 days for transported versus nontransported patients. When subset by diabetes type, odds of recurrent severe hypoglycemia among transported patients were 0.64 (95% CI 0.43-0.96) and 0.42 (95% CI 0.24-0.75) in type 1 and type 2 diabetes, respectively. CONCLUSIONS Transported patients experienced recurrent hypoglycemia requiring medical attention approximately half as often as nontransported patients, reinforcing the importance of engaging patients in follow-up to prevent recurrent events.
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Affiliation(s)
| | - Kristi M Swanson
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN
| | - Amy E Glasgow
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN
| | - Rozalina G McCoy
- Mayo Clinic Ambulance Service, Rochester, MN.,Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN.,Division of Community Internal Medicine, Geriatrics, and Palliative Care, Department of Medicine, Mayo Clinic, Rochester, MN
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7
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Couturier K, Nelson AR, Burns K, Cone DC, Rollins M, Venkatesh AK, Ulrich A, Shapiro M, Joseph D. EMS Non-Transport of Low-Risk COVID-19 Patients. PREHOSP EMERG CARE 2022; 27:310-314. [PMID: 35639643 DOI: 10.1080/10903127.2022.2083278] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVES COVID-19 infections in the community have the potential to overwhelm both prehospital and in-hospital resources. Transport of well-appearing patients, in the absence of available emergency department treatment capacity, increases strain on the hospital and EMS system. In May of 2020, the Connecticut Office of EMS issued a voluntary, EMS-initiated, non-transport protocol for selected low-risk patients with symptoms consistent with COVID-19. We evaluated the implementation of this non-transport protocol in a mixed urban/suburban EMS system. METHODS We conducted a retrospective review of contemporaneously recorded quality improvement documentation for uses of the Connecticut COVID-19 non-transport protocol by EMS clinicians within our EMS system during two implementations: from 12/14/2020 to 5/1/21, and again from 1/3/22 to 2/18/22, which coincided with large COVID-19 case surges in our region. RESULTS The vast majority of patients treated under the non-transport protocol were not re-evaluated by EMS or in our emergency departments in the subsequent 24 hours. There was reasonable adherence to the protocol, with 83% of cases appropriate for the non-transport protocol. The most common reasons for protocol violations were age outside of protocol scope (pediatric patients), failure of documentation, or vital signs outside of the established protocol parameters. We did not find an increased 24-hour ED visit rate in patients who were inappropriately triaged to the protocol. Of patients who had ED visits within 24 hours, only two were admitted, none to higher levels of care. CONCLUSION Within this small study, EMS clinicians in our system were able to safely and accurately apply a non-transport protocol for patients presenting with symptoms consistent with COVID-19. This is consistent with previous literature suggesting that EMS-initiated non-transport is a viable strategy to reduce the burden on health systems.
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Affiliation(s)
- Katherine Couturier
- From the Section of EMS, Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Alexander R Nelson
- From the Section of EMS, Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Kevin Burns
- From the Section of EMS, Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - David C Cone
- From the Section of EMS, Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Mark Rollins
- From the Section of EMS, Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Arjun K Venkatesh
- From the Section of EMS, Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Andrew Ulrich
- From the Section of EMS, Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Matthew Shapiro
- From the Section of EMS, Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Daniel Joseph
- From the Section of EMS, Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT, USA
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8
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Haamid A, Christian E, Tataris K, Markul E, Zaidi HQ, Mycyk MB, Weber JM. Prehospital Intranasal Glucagon for Hypoglycemia. PREHOSP EMERG CARE 2022; 27:356-359. [PMID: 35200091 DOI: 10.1080/10903127.2022.2045406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Background: Prehospital hypoglycemia is usually treated with oral or intravenous (IV) dextrose in a variety of concentrations. In the absence of vascular access, intramuscular (IM) glucagon is commonly administered. Occupational needle-stick injury remains a significant risk while attempting to obtain vascular access or administer medications intramuscularly in the prehospital setting. We sought to determine if intranasal (IN) glucagon is effective in the prehospital treatment of hypoglycemia.Methods: We performed a retrospective analysis of all consecutive cases where recombinant glucagon was administered IN by paramedics from January 1, 2015 through December 31, 2020. Excluded were cases without pre or post administration blood glucose documentation, and cases where another form of treatment for hypoglycemia was administered at any time during the EMS encounter. The primary outcome was clinical response to IN glucagon documented by paramedics; secondary outcomes included pre and post administration blood glucose values.Results: Out of 44 cases that met study inclusion criteria, 14 patients (32%) had substantial improvement, 13 patients (30%) had slight improvement, and 17 patients (38%) had no improvement in mental status after administration of IN glucagon. In cases with substantial improvement (n = 14), the mean pre administration blood glucose was 33.8 mg/dl and the mean post administration blood glucose was 87.1 mg/dl (mean increase 53.3 mg/dl, 95% CI: 21.5 to 85.1). In cases with slight improvement (n = 13), the mean pre administration blood glucose was 23.9 mg/dl and the mean post administration blood glucose was 53.8 mg/dl (mean increase 29.9 mg/dl, 95% CI =2.9 to 56.9). In case with no improvement (n = 17) the mean pre administration blood glucose was 30.1 mg/dl and the mean post administration glucose was 33.1 mg/dl (mean difference 3.1 mg/dl, 95% CI: -10.1 to 3.9).Conclusion: Intranasal administration of recombinant glucagon for hypoglycemia resulted in a clinically significant improvement in mental status and a corresponding increase in blood glucose levels in select cases in the prehospital setting.
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Affiliation(s)
- Ameera Haamid
- Department of Emergency Medicine, Cook County Health
| | | | - Katie Tataris
- Section of Emergency Medicine, University of Chicago
| | - Eddie Markul
- Department of Emergency Medicine, Advocate Illinois Masonic Medical Center
| | - Hashim Q Zaidi
- Department of Emergency Medicine, University of Texas Health Science Center at Houston
| | - Mark B Mycyk
- Department of Emergency Medicine, Cook County Health
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Hutchcraft ML, Ola O, McLaughlin EM, Hade EM, Murphy AJ, Frey HA, Larrimore A, Panchal AR. A One-Year Cross Sectional Analysis of Emergency Medical Services Utilization and Its Association with Hypertension in Pregnancy. PREHOSP EMERG CARE 2021; 26:838-847. [PMID: 34605746 DOI: 10.1080/10903127.2021.1988775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Objective: To evaluate the prehospital obstetric population that utilizes emergency medical services (EMS) and their association with hypertensive disorders of pregnancy.Methods: We conducted a retrospective evaluation of one year of all medical calls from a large, municipal, midwestern fire department. Inclusion criteria included all pregnant patients transported to a hospital by EMS. Descriptive statistics were calculated to evaluate prehospital event information (e.g., zip code, time, and duration of call), patient characteristics, and clinical management data regarding blood pressure. Census data were used to compare neighborhood information with poverty rates.Results: Of the 1,575 identified patients, 64.4% (1015/1575) presented with obstetric complaints, 57.4% (700/1220) were in their third trimester and 72.7% (686/944) were multiparous. The median call duration was 17 (interquartile range 12-22) minutes. In the areas where EMS usage was highest, one quarter of individuals lived below the poverty level. Of the studied population, 32.0% (504/1575) were found to be hypertensive; 14.9% (75/504) of hypertensive patients were found to have severe hypertension. Only one patient (1/1575, 0.06%) presented with a chief complaint of hypertension; the rest were discovered by EMS. The highest rates of hypertension were noted in wealthier areas of the city. Patients with severe hypertension were more likely to present with seizures, consistent with eclampsia.Conclusion: Hypertension is common in the obstetric population using EMS. Prehospital management of hypertensive disorders of pregnancy may focus on identification and treatment of severe pre-eclampsia or eclampsia. Areas with longer call times may consider treatment of severe hypertension. Prehospital treatment of hypertensive disorders of pregnancy could be optimized.
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Affiliation(s)
- Megan L Hutchcraft
- Received July 18, 2021 from Department of Obstetrics and Gynecology, The Ohio State University Wexner Medical Center, Columbus, OH, USA (MLH); College of Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA (OO); Department of Biomedical Informatics, The Ohio State University, Columbus, OH, USA (EMM, EMH); City of Columbus (Ohio), Division of Fire, Columbus, OH, USA (AJM); Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA (HAF); Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA (AL, ARP). Revision received September 28, 2021; accepted for publication September 29, 2021
| | - Oluwabusola Ola
- Received July 18, 2021 from Department of Obstetrics and Gynecology, The Ohio State University Wexner Medical Center, Columbus, OH, USA (MLH); College of Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA (OO); Department of Biomedical Informatics, The Ohio State University, Columbus, OH, USA (EMM, EMH); City of Columbus (Ohio), Division of Fire, Columbus, OH, USA (AJM); Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA (HAF); Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA (AL, ARP). Revision received September 28, 2021; accepted for publication September 29, 2021
| | - Eric M McLaughlin
- Received July 18, 2021 from Department of Obstetrics and Gynecology, The Ohio State University Wexner Medical Center, Columbus, OH, USA (MLH); College of Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA (OO); Department of Biomedical Informatics, The Ohio State University, Columbus, OH, USA (EMM, EMH); City of Columbus (Ohio), Division of Fire, Columbus, OH, USA (AJM); Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA (HAF); Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA (AL, ARP). Revision received September 28, 2021; accepted for publication September 29, 2021
| | - Erinn M Hade
- Received July 18, 2021 from Department of Obstetrics and Gynecology, The Ohio State University Wexner Medical Center, Columbus, OH, USA (MLH); College of Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA (OO); Department of Biomedical Informatics, The Ohio State University, Columbus, OH, USA (EMM, EMH); City of Columbus (Ohio), Division of Fire, Columbus, OH, USA (AJM); Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA (HAF); Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA (AL, ARP). Revision received September 28, 2021; accepted for publication September 29, 2021
| | - Andrew J Murphy
- Received July 18, 2021 from Department of Obstetrics and Gynecology, The Ohio State University Wexner Medical Center, Columbus, OH, USA (MLH); College of Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA (OO); Department of Biomedical Informatics, The Ohio State University, Columbus, OH, USA (EMM, EMH); City of Columbus (Ohio), Division of Fire, Columbus, OH, USA (AJM); Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA (HAF); Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA (AL, ARP). Revision received September 28, 2021; accepted for publication September 29, 2021
| | - Heather A Frey
- Received July 18, 2021 from Department of Obstetrics and Gynecology, The Ohio State University Wexner Medical Center, Columbus, OH, USA (MLH); College of Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA (OO); Department of Biomedical Informatics, The Ohio State University, Columbus, OH, USA (EMM, EMH); City of Columbus (Ohio), Division of Fire, Columbus, OH, USA (AJM); Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA (HAF); Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA (AL, ARP). Revision received September 28, 2021; accepted for publication September 29, 2021
| | - Ashley Larrimore
- Received July 18, 2021 from Department of Obstetrics and Gynecology, The Ohio State University Wexner Medical Center, Columbus, OH, USA (MLH); College of Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA (OO); Department of Biomedical Informatics, The Ohio State University, Columbus, OH, USA (EMM, EMH); City of Columbus (Ohio), Division of Fire, Columbus, OH, USA (AJM); Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA (HAF); Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA (AL, ARP). Revision received September 28, 2021; accepted for publication September 29, 2021
| | - Ashish R Panchal
- Received July 18, 2021 from Department of Obstetrics and Gynecology, The Ohio State University Wexner Medical Center, Columbus, OH, USA (MLH); College of Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA (OO); Department of Biomedical Informatics, The Ohio State University, Columbus, OH, USA (EMM, EMH); City of Columbus (Ohio), Division of Fire, Columbus, OH, USA (AJM); Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA (HAF); Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA (AL, ARP). Revision received September 28, 2021; accepted for publication September 29, 2021
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10
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Dextrose 50% versus Dextrose 10% or Dextrose Titration for the Treatment of Out-of-Hospital Hypoglycemia: A Systematic Review. Prehosp Disaster Med 2021; 36:730-738. [PMID: 34605385 DOI: 10.1017/s1049023x21001047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Paramedics commonly administer intravenous (IV) dextrose to severely hypoglycemic patients. Typically, the treatment provided is a 25g ampule of 50% dextrose (D50). This dose of D50 is meant to ensure a return to consciousness. However, this dose may cause harm and lead to difficulties regulating blood glucose levels (BGLs) post-treatment. It is hypothesized that a lower concentration, such as 10% dextrose (D10), may improve symptoms while minimizing harm. METHODS PubMed, Embase, CINAHL, and Cochrane Central were systematically searched on September 15, 2020. The PRISMA guidelines were followed. GRADE and risk of bias were applied to determine the certainty of the evidence. Primary literature investigating the use of IV dextrose in hypoglycemic diabetic patients presenting to paramedics or the emergency department was included. Outcomes of interest included safety, efficacy (symptom resolution), and BGL. RESULTS Of 680 abstracts screened, 51 full-text articles were reviewed, with eleven studies included. Data from three randomized controlled trials (RCTs) and eight observational studies were analyzed. A single RCT comparing D10 to D50 was identified. The primary significant finding of the study was an increased post-treatment glycemic profile by 3.2mmol/L in the D50 group; no other outcomes had significant differences between groups. When comparing pooled data from all the included studies, there was greater symptom resolution in the D10 group (95.9%) compared to the D50 group (88.8%). However, the mean time to resolution was approximately four minutes longer in the D10 group (4.1 minutes [D50] versus 8.0 minutes [D10]). There was a greater need for subsequent doses with the use of D10 (19.5%) compared to D50 (8.1%). The post-treatment glycemic profile was lower in the D10 group at 6.2mmol/L versus 8.5mmol/L in the D50 group. Both treatments had nearly complete resolution of hypoglycemia: 98.7% (D50) and 99.2% (D10). No adverse events were observed in the D10 group (0/1057) compared to 13/310 adverse events in the D50 group. CONCLUSION Studies show D10 may be as effective as D50 at resolving symptoms and correcting hypoglycemia. Although the desired effect can take several minutes longer, there appear to be fewer adverse events. The post-D10-treatment BGL may result in fewer untoward hyperglycemic episodes.
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11
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Regional differences in patient age and prostate cancer characteristics and rates of treatment modalities in favorable and unfavorable intermediate risk prostate cancer across United States SEER registries. Cancer Epidemiol 2021; 74:101994. [PMID: 34364187 DOI: 10.1016/j.canep.2021.101994] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 07/01/2021] [Accepted: 07/15/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Intermediate risk (IR) prostate cancer (PCa) is a highly heterogeneous entity and can be distinguished into favorable and unfavorable IR PCa according to biopsy, PSA and cT-stage characteristics. These differences may translate into differences in treatment type. METHODS We tested for differences in PCa tumor characteristics and differences in active treatment rates (radical prostatectomy [RP], external beam radiotherapy [EBRT]) according to Surveillance, Epidemiology and End Results (SEER) registry (2010-2015) in favorable and unfavorable IR PCa. Data were stratified according to individual SEER registries. Further analyses additionally adjusted for PCa baseline characteristics (PSA, cT stage, biopsy Gleason group grading [GGG], percentage of positive biopsy cores). RESULTS Tabulations according to SEER registries showed that, in favorable IR vs. unfavorable IR, the rates of RP and EBRT respectively ranged from 30.0 to 54.3% vs. 30.3-55.5 % and 8.3-44.7 % vs. 11.5-45.5 %. Differences in age and baseline PCa tumor characteristics also existed in both favorable and unfavorable IR across SEER registries. After adjustment for those baseline patient and PCa characteristics (PSA, cT stage, GGG, percentage of positive biopsy cores), RP and EBRT rates exhibited virtually no residual differences across individual SEER registries, in both favorable (36.0-41.0 % and 26.8-28.1 %) and unfavorable IR PCa (39.2-42.0% and 31.1-33.5 %). CONCLUSION Important differences may be identified in treatment rates within the examined 18 SEER registries in favorable and in unfavorable IR PCa. However, the observed differences are virtually entirely explained by differences in baseline PCa characteristics.
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Van de Voorde P, Turner NM, Djakow J, de Lucas N, Martinez-Mejias A, Biarent D, Bingham R, Brissaud O, Hoffmann F, Johannesdottir GB, Lauritsen T, Maconochie I. [Paediatric Life Support]. Notf Rett Med 2021; 24:650-719. [PMID: 34093080 PMCID: PMC8170638 DOI: 10.1007/s10049-021-00887-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2021] [Indexed: 12/11/2022]
Abstract
The European Resuscitation Council (ERC) Paediatric Life Support (PLS) guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations of the International Liaison Committee on Resuscitation (ILCOR). This section provides guidelines on the management of critically ill or injured infants, children and adolescents before, during and after respiratory/cardiac arrest.
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Affiliation(s)
- Patrick Van de Voorde
- Department of Emergency Medicine, Faculty of Medicine UG, Ghent University Hospital, Gent, Belgien
- Federal Department of Health, EMS Dispatch Center, East & West Flanders, Brüssel, Belgien
| | - Nigel M. Turner
- Paediatric Cardiac Anesthesiology, Wilhelmina Children’s Hospital, University Medical Center, Utrecht, Niederlande
| | - Jana Djakow
- Paediatric Intensive Care Unit, NH Hospital, Hořovice, Tschechien
- Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital Brno, Medical Faculty of Masaryk University, Brno, Tschechien
| | | | - Abel Martinez-Mejias
- Department of Paediatrics and Emergency Medicine, Hospital de Terassa, Consorci Sanitari de Terrassa, Barcelona, Spanien
| | - Dominique Biarent
- Paediatric Intensive Care & Emergency Department, Hôpital Universitaire des Enfants, Université Libre de Bruxelles, Brüssel, Belgien
| | - Robert Bingham
- Hon. Consultant Paediatric Anaesthetist, Great Ormond Street Hospital for Children, London, Großbritannien
| | - Olivier Brissaud
- Réanimation et Surveillance Continue Pédiatriques et Néonatales, CHU Pellegrin – Hôpital des Enfants de Bordeaux, Université de Bordeaux, Bordeaux, Frankreich
| | - Florian Hoffmann
- Pädiatrische Intensiv- und Notfallmedizin, Kinderklinik und Kinderpoliklinik im Dr. von Haunerschen Kinderspital, Ludwig-Maximilians-Universität, München, Deutschland
| | | | - Torsten Lauritsen
- Paediatric Anaesthesia, The Juliane Marie Centre, University Hospital of Copenhagen, Kopenhagen, Dänemark
| | - Ian Maconochie
- Paediatric Emergency Medicine, Faculty of Medicine Imperial College, Imperial College Healthcare Trust NHS, London, Großbritannien
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13
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Erste Hilfe. Notf Rett Med 2021. [DOI: 10.1007/s10049-021-00886-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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14
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Chuck CC, Martin TJ, Kalagara R, Shaaya E, Kheirbek T, Cielo D. Emergency medical services protocols for traumatic brain injury in the United States: A call for standardization. Injury 2021; 52:1145-1150. [PMID: 33487407 DOI: 10.1016/j.injury.2021.01.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Revised: 01/01/2021] [Accepted: 01/06/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Traumatic brain injury (TBI) with acute elevation in intracranial pressure (ICP) is a neurologic emergency associated with significant morbidity and mortality. In addition to indicated trauma resuscitation, emergency department (ED) management includes empiric administration of hyperosmolar agents, rapid diagnostic imaging, anticoagulation reversal, and early neurosurgical consultation. Despite optimization of in-hospital care, patient outcomes may be worsened by variation in prehospital management. In this study, we evaluate geographic variation between emergency medical services (EMS) protocols for patients with suspected TBI. METHODS We performed a cross-sectional analysis of statewide EMS protocols in the United States in December 2020 and included all complete protocols published on government websites. Outcome measures were defined to include protocols or orders for the following interventions, given TBI: (1) hyperventilation and end-tidal capnography (EtCO2) goals, (2) administration of hyperosmolar agents, (3) tranexamic acid (TXA) administration for isolated head injury, (4) non-invasive management including head-of-bed elevation, and (5) hemodynamic goals. RESULTS We identified 32 statewide protocols including Washington, D.C., 4 of which did not include specific guidance for TBI. Of 28 states providing ventilatory guidance, 22/28 (78.6%) recommend hyperventilation, with 17/22 (77.3%) restricting hyperventilation to signs of acute herniation. The remaining 6 states prohibited hyperventilation. Regarding EtCO2 goals among states permitting hyperventilation, 17/22 (77.3%) targeted an EtCO2 of < 35 mmHg, while 5/22 (22.7%) provided no guide EtCO2 for hyperventilation. Rhode Island was the only state identified that included hypertonic saline (3%), and Delaware was the only state that allowed TXA in the setting of isolated TBI with GCS ≤ 12. Only 15/32 (46.9%) identified states recommend head-of-bed elevation. For blood pressure goals, 12/28 (42.9%) of states set minimum systolic blood pressure at 90 mmHg, while 10/28 (35.7%) set other SBP goals. The remaining 6/28 (21.4%) did not provide TBI-specific SBP goals. CONCLUSIONS There is wide variation among civilian prehospital protocols for traumatic brain injury. Prehospital care within the first "golden hour" may dramatically affect patient outcomes. Neurocritical care providers should be mindful of geographic variation in local protocols when designing and evaluating quality improvement interventions and should aim to standardize prehospital care protocols.
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Affiliation(s)
- Carlin C Chuck
- The Warren Alpert Medical School of Brown University, Providence, RI, United States..
| | - Thomas J Martin
- The Warren Alpert Medical School of Brown University, Providence, RI, United States
| | - Roshini Kalagara
- Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Elias Shaaya
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence, RI, United States
| | - Tareq Kheirbek
- Department of Surgery, The Warren Alpert Medical School of Brown University, Providence, RI, United States
| | - Deus Cielo
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence, RI, United States
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15
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Zideman DA, Singletary EM, Borra V, Cassan P, Cimpoesu CD, De Buck E, Djärv T, Handley AJ, Klaassen B, Meyran D, Oliver E, Poole K. European Resuscitation Council Guidelines 2021: First aid. Resuscitation 2021; 161:270-290. [PMID: 33773828 DOI: 10.1016/j.resuscitation.2021.02.013] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The European Resuscitation Council has produced these first aid guidelines, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics include the first aid management of emergency medicine and trauma. For medical emergencies the following content is covered: recovery position, optimal positioning for shock, bronchodilator administration for asthma, recognition of stroke, early aspirin for chest pain, second dose of adrenaline for anaphylaxis, management of hypoglycaemia, oral rehydration solutions for treating exertion-related dehydration, management of heat stroke by cooling, supplemental oxygen in acute stroke, and presyncope. For trauma related emergencies the following topics are covered: control of life-threatening bleeding, management of open chest wounds, cervical spine motion restriction and stabilisation, recognition of concussion, cooling of thermal burns, dental avulsion, compression wrap for closed extremity joint injuries, straightening an angulated fracture, and eye injury from chemical exposure.
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Affiliation(s)
| | | | - Vere Borra
- Centre for Evidence-based Practice, Belgian Red Cross, Mechelen, Belgium; Cochrane First Aid, Mechelen, Belgium
| | - Pascal Cassan
- International Federation of Red Cross and Red Crescent, France
| | - Carmen D Cimpoesu
- University of Medicine and Pharmacy "Grigore T. Popa", Iasi, Emergency Department and Prehospital EMS SMURD Iasi Emergency County Hospital "Sf. Spiridon" Iasi, Romania
| | - Emmy De Buck
- Centre for Evidence-based Practice, Belgian Red Cross, Mechelen, Belgium; Cochrane First Aid, Mechelen, Belgium; Department of Public Health and Primary Care, Faculty of Medicine, KU Leuven, Leuven, Belgium
| | - Therese Djärv
- Department of Medicine Solna, Karolinska Institute and Division of Acute and Reparative Medicine, Karolinska University Hospital, Sweden
| | | | - Barry Klaassen
- Emergency Medicine, Ninewells Hospital and Medical School Dundee, UK; British Red Cross, UK
| | - Daniel Meyran
- French Red Cross, Bataillon de Marins Pompiers de Marseille, France
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16
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Van de Voorde P, Turner NM, Djakow J, de Lucas N, Martinez-Mejias A, Biarent D, Bingham R, Brissaud O, Hoffmann F, Johannesdottir GB, Lauritsen T, Maconochie I. European Resuscitation Council Guidelines 2021: Paediatric Life Support. Resuscitation 2021; 161:327-387. [PMID: 33773830 DOI: 10.1016/j.resuscitation.2021.02.015] [Citation(s) in RCA: 173] [Impact Index Per Article: 57.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
These European Resuscitation Council Paediatric Life Support (PLS) guidelines, are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the management of critically ill infants and children, before, during and after cardiac arrest.
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Affiliation(s)
- Patrick Van de Voorde
- Department of Emergency Medicine Ghent University Hospital, Faculty of Medicine UG, Ghent, Belgium; EMS Dispatch Center, East & West Flanders, Federal Department of Health, Belgium.
| | - Nigel M Turner
- Paediatric Cardiac Anesthesiology, Wilhelmina Children's Hospital, University Medical Center, Utrecht, Netherlands
| | - Jana Djakow
- Paediatric Intensive Care Unit, NH Hospital, Hořovice, Czech Republic; Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital Brno, Medical Faculty of Masaryk University, Brno, Czech Republic
| | | | - Abel Martinez-Mejias
- Department of Paediatrics and Emergency Medicine, Hospital de Terassa, Consorci Sanitari de Terrassa, Barcelona, Spain
| | - Dominique Biarent
- Paediatric Intensive Care & Emergency Department, Hôpital Universitaire des Enfants, Université Libre de Bruxelles, Brussels, Belgium
| | - Robert Bingham
- Hon. Consultant Paediatric Anaesthetist, Great Ormond Street Hospital for Children, London, UK
| | - Olivier Brissaud
- Réanimation et Surveillance Continue Pédiatriques et Néonatales, CHU Pellegrin - Hôpital des Enfants de Bordeaux, Université de Bordeaux, Bordeaux, France
| | - Florian Hoffmann
- Paediatric Intensive Care and Emergency Medicine, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University, Munich, Germany
| | | | - Torsten Lauritsen
- Paediatric Anaesthesia, The Juliane Marie Centre, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Ian Maconochie
- Paediatric Emergency Medicine, Imperial College Healthcare Trust NHS, Faculty of Medicine Imperial College, London, UK
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17
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Weant KA, Deloney L, Elsey G, Combs D, French D. A Comparison of 10% Dextrose and 50% Dextrose for the Treatment of Hypoglycemia in the Prehospital Setting. J Pharm Pract 2019; 34:606-611. [PMID: 31769338 DOI: 10.1177/0897190019889444] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Hypoglycemia is a frequent cause of emergency medical services (EMS) activation; however, limited evidence exists to support optimal prehospital treatment. OBJECTIVE This study sought to compare the safety and efficacy of the administration of 10% dextrose (D10) intravenously (IV) versus 50% dextrose (D50) IV for the treatment of hypoglycemia in the prehospital setting. METHODS This was a retrospective cohort study of patients who received IV dextrose by EMS and were transported to an academic teaching hospital emergency department between 2014 and 2017. RESULTS Four hundred seventy-eight eligible patients were reviewed, with 161 patients receiving D10 and 150 patients receiving D50. There was no significant difference found regarding the need for dextrose retreatment prior to hospital arrival between the D10 and D50 groups (0.6% vs 2.0%; P = .565). The prehospital reassessment glucose in the D50 group was a significantly higher than the D10 group (151.9 vs 124.6 mg/dL, P = .001) and this difference was maintained on hospital arrival (129.5 vs 108.0 mg/dL, P = .011). No significant difference was found between groups with regard to hospital admission, length of stay, or in-hospital mortality. CONCLUSION When comparing D10 with D50 for the treatment of hypoglycemia by EMS, there were no significant differences in the need for dextrose retreatment prior to hospital arrival. The use of D50 resulted in a significantly higher blood glucose concentrations both in the prehospital setting and upon hospital arrival. Further study is needed in larger patient populations to evaluate the use of D10, the need for dextrose readministration, and its impact on clinical outcomes.
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Affiliation(s)
- Kyle A Weant
- College of Pharmacy, 2345Medical University of South Carolina, Charleston, SC, USA
| | - Lindsay Deloney
- College of Pharmacy, 2345Medical University of South Carolina, Charleston, SC, USA
| | - Grace Elsey
- College of Pharmacy, 2345Medical University of South Carolina, Charleston, SC, USA
| | | | - David French
- Charleston County EMS, Charleston, SC, USA.,Department of Emergency Medicine, 2345Medical University of South Carolina, Charleston, SC, USA
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18
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O'Connor L, Kue RC, O'Connor MJ. Characteristics of Patients with Recurrent Emergency Medical Services Utilization for Symptomatic Hypoglycemia in an Urban Setting. PREHOSP EMERG CARE 2019; 23:780-787. [PMID: 30893563 DOI: 10.1080/10903127.2019.1587125] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Background: Symptomatic hypoglycemia frequently results in utilization of emergency medical services (EMS). Understanding the characteristics of hypoglycemic patients with high EMS utilization may help providers optimize resource allocation. Objective: To describe characteristics of patients utilizing EMS for hypoglycemia and to determine if any factors identifiable in the prehospital setting are associated with recurrent EMS utilization. Methods: A retrospective chart review of prehospital care records from an urban EMS system was performed. Patients who received oral glucose, parenteral glucose, or intramuscular glucagon for hypoglycemia over a one-year period were identified. Extracted information included demographics, prehospital treatment, disposition, zip code median income, and the number of subsequent EMS utilizations within 365 days. Results: We identified 549 subjects, mean age 55 years (range 5 to 104, 65% male). The mean glucose level for all patients was 44 mg/dl with standard deviation (SD) of 15. In total, 69% of patients received oral glucose, 26% received parenteral glucose, 3% received glucagon, and 2% received more than one medication. At the index visit, 81% of patients accepted hospital transportation. The rate of recurrent EMS utilization for hypoglycemia was 10%, and 3% of patients had 3 or more repeat utilizations within 365 days. The mean finger-stick glucose at index visit was 39 mg/dL (SD 15) for patients with multiple EMS utilizations and 44 mg/dL (SD 14) for those with one EMS visit (P = 0.006). Repeat utilizers were more likely to have received medications other than oral glucose at index visit, 51% vs. 28% (P < 0.001). Age, gender, median zip code income, and disposition were not associated with recurrent EMS utilization. The overall annual rate of hypoglycemia requiring EMS treatment per estimated diabetic population was 0.84%. Conclusion: A low proportion of patients utilizing EMS for hypoglycemia had subsequent EMS visits within 365 days. Those who did had lower initial blood glucose at the index visit and were more likely to have received prehospital treatment with medications other than oral glucose. Demographic characteristics did not yield any patterns predictive of repeat utilization. Refusing transport to the hospital after EMS treatment for hypoglycemia did not increase the risk of recurrent utilization.
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Pöhlmann J, Mitchell BD, Bajpai S, Osumili B, Valentine WJ. Nasal Glucagon Versus Injectable Glucagon for Severe Hypoglycemia: A Cost-Offset and Budget Impact Analysis. J Diabetes Sci Technol 2019; 13:910-918. [PMID: 30700165 PMCID: PMC6955465 DOI: 10.1177/1932296819826577] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Severe hypoglycemic events (SHEs) in patients with diabetes are associated with substantial health care costs in the United States (US). Injectable glucagon (IG) is currently available for treatment of severe hypoglycemia but is associated with frequent handling errors. Nasal glucagon (NG) is a novel, easier-to-use treatment that is more often administered successfully. The economic impact of this usability advantage was explored in cost-offset and budget impact analyses for the US setting. METHODS A health economic model was developed to estimate mean costs per SHE for which treatment was attempted using NG or IG, which differed only in the probability of treatment success, based on a published usability study. The budget impact of NG was projected over 2 years for patients with type 1 diabetes (T1D) and type 2 diabetes treated with basal-bolus insulin (T2D-BB). Epidemiologic and cost data were sourced from the literature and/or fee schedules. RESULTS Mean costs were $992 lower if NG was used compared with IG per SHE for which a user attempted treatment. NG was estimated to reduce SHE-related spending by $1.1 million and $230 000 over 2 years in 10 000 patients each with T1D and T2D-BB, respectively. Reduced spending resulted from reduced professional emergency services utilization as successful treatment was more likely with NG. CONCLUSIONS The usability advantage of NG over IG was projected to reduce SHE-related treatment costs in the US setting. NG has the potential to improve hypoglycemia emergency care and reduce SHE-related treatment costs.
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De Buck E, Borra V, Carlson JN, Zideman DA, Singletary EM, Djärv T. First aid glucose administration routes for symptomatic hypoglycaemia. Cochrane Database Syst Rev 2019; 4:CD013283. [PMID: 30973639 PMCID: PMC6459163 DOI: 10.1002/14651858.cd013283.pub2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Hypoglycaemia is a common occurrence in people with diabetes but can also result from an imbalance in glucose homeostasis in the absence of diabetes. The best enteral route for glucose administration for suspected hypoglycaemia in a first aid situation is unknown. OBJECTIVES To assess the effects of first aid glucose administration by any route appropriate for use by first-aid providers (buccal, sublingual, oral, rectal) for symptomatic hypoglycaemia. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, CINAHL as well as grey literature (records identified in the WHO ICTRP Search Portal, ClinicalTrials.gov and the EU Clinical Trials Register) up to July 2018. We searched reference lists of included studies retrieved by the above searches. SELECTION CRITERIA We included studies involving adults and children with documented or suspected hypoglycaemia as well as healthy volunteers, in which glucose was administered by any enteral route appropriate for use by first-aid providers. DATA COLLECTION AND ANALYSIS Two review authors independently selected trials, assessed risk of bias, extracted data and evaluated trials for overall certainty of the evidence using the GRADE instrument. We used the Cochrane 'Risk of bias' tool to assess the risk of bias in the randomised controlled trials (RCTs), and the 'risk of bias In non-randomised studies of interventions' (ROBINS-I) tool, in addition to the Cochrane Handbook for Systematic Reviews of Interventions recommendations on cross-over studies, for the non-RCTs. We reported continuous outcomes as mean differences (MD) with 95% confidence intervals (CIs) and dichotomous outcomes as risk ratios (RR) with 95% CIs. All data on glucose concentrations were converted to mg/dL. We contacted authors of included studies to obtain missing data. MAIN RESULTS From 6394 references, we included four studies evaluating 77 participants, including two RCTs, studying children and adults with hypoglycaemia, respectively, and two non-RCTs with healthy volunteers. The studies included three different routes of glucose administration (sublingual, buccal and a combination of oral and buccal administration). All studies had a high risk of bias in one or more 'Risk of bias' domain.Glucose administration by the sublingual route, in the form of table sugar under the tongue, resulted in a higher blood glucose concentration after 20 minutes compared with the oral route in the very specific setting of children with hypoglycaemia and symptoms of concomitant malaria or respiratory tract infection (MD 17 mg/dL, 95% CI 4.4 to 29.6; P = 0.008; 1 study; 42 participants; very low-quality evidence). Resolution of hypoglycaemia at 80 minutes may favour sublingual administration (RR 2.10, 95% CI 1.24 to 3.54; P = 0.006; 1 study; 42 participants; very low-certainty evidence), but no substantial difference could be demonstrated at 20 minutes (RR 1.26, 95% CI 0.91 to 1.74; P = 0.16; 1 study; 42 participants; very low-certainty evidence). A decrease in the time to resolution of hypoglycaemia was found in favour of sublingual administration (MD -51.5 min, 95% CI -58 to -45; P < 0.001; 1 study; 42 participants; very low-certainty evidence). No adverse events were reported in either group. No data were available for resolution of symptoms and time to resolution of symptoms, and treatment delay.Glucose administered by the buccal route in one study resulted in a lower plasma glucose concentration after 20 minutes compared with oral administration (MD -14.4 mg/dL, 95% CI -17.5 to -11.4 for an imputed within-participants correlation coefficient of 0.9; P < 0.001; 1 trial; 16 participants; very low-quality evidence). In another study there were fewer participants with increased blood glucose at 20 minutes favouring oral glucose (RR 0.07, 95% CI 0.00 to 0.98; P = 0.05; 1 study; 7 participants; very low-certainty evidence). No data were available for resolution of symptoms and time to resolution of symptoms, resolution of hypoglycaemia and time to resolution of hypoglycaemia, adverse events, and treatment delay.For the combined oral and buccal mucosal route (in the form of a dextrose gel) the MD was -15.3 mg/dL, 95%CI -33.6 to 3; P = 0.09; 1 study; 18 participants; very low-quality evidence . No improvement was identified for either route in the resolution of symptoms at 20 minutes or less following glucose administration (RR 0.36, 95% CI 0.12 to 1.14; P = 0.08; 1 study; 18 participants; very low-certainty evidence). No data were available for time to resolution of symptoms, resolution of hypoglycaemia and time to resolution of hypoglycaemia, adverse events, and treatment delay. AUTHORS' CONCLUSIONS When providing first aid to individuals with hypoglycaemia, oral glucose administration results in a higher blood glucose concentrations after 20 minutes when compared with buccal administration of glucose. A difference in plasma glucose concentration could not be demonstrated, when administering a dextrose gel, defined as "a combined oral and buccal mucosal route" compared to oral administration of a glucose tablet or solution. In the specific population of children with concomitant malaria and respiratory illness, sublingual sugar results in a higher blood glucose concentration after 20 minutes when compared with oral administration.These results need to be interpreted cautiously because our confidence in the body of evidence is very low due to the low number of participants and studies as well as methodological deficiencies in the included studies.
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Affiliation(s)
- Emmy De Buck
- Belgian Red CrossCentre for Evidence‐Based Practice (CEBaP)Motstraat 42MechelenBelgium2800
| | - Vere Borra
- Belgian Red CrossCentre for Evidence‐Based Practice (CEBaP)Motstraat 42MechelenBelgium2800
| | - Jestin N Carlson
- Allegheny Health NetworkEmergency Department232 West 25th StEriePennsylvaniaUSA16544
| | - David A Zideman
- Thames Valley Air AmbulanceStokenchurch House, Oxford RoadStokenchurchUKHP14 3SX
| | - Eunice M Singletary
- University of Virginia School of MedicineDepartment of Emergency MedicineLee StreetCharlottesvilleVirginiaUSA22908
| | - Therese Djärv
- Karolinska University HospitalFunction of Emergency MedicineStockholmStockholmSweden17100
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21
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De Buck E, Borra V, Carlson JN, Zideman DA, Singletary EM, Djärv T. First aid glucose administration routes for symptomatic hypoglycaemia. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2019. [DOI: 10.1002/14651858.cd013283] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Emmy De Buck
- Belgian Red Cross; Centre for Evidence-Based Practice (CEBaP); Motstraat 42 Mechelen Belgium 2800
| | - Vere Borra
- Belgian Red Cross; Centre for Evidence-Based Practice (CEBaP); Motstraat 42 Mechelen Belgium 2800
| | - Jestin N Carlson
- Allegheny Health Network; Emergency Department; 232 West 25th St Erie Pennsylvania USA 16544
| | - David A Zideman
- Thames Valley Air Ambulance; Stokenchurch House, Oxford Road Stokenchurch UK HP14 3SX
| | - Eunice M Singletary
- University of Virginia School of Medicine; Department of Emergency Medicine; Lee Street Charlottesville Virginia USA 22908
| | - Therese Djärv
- Karolinska University Hospital; Function of Emergency Medicine; Stockholm Stockholm Sweden 17100
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22
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Pruett K, White Iv CC, Braude D. Underutilization of Glucagon in the Prehospital Setting. Ann Intern Med 2018; 169:426. [PMID: 30242411 DOI: 10.7326/l18-0298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Kimberly Pruett
- University of New Mexico Health Sciences Center, Albuquerque, New Mexico (K.P., D.B.)
| | - Chelsea C White Iv
- University of New Mexico Center for Rural and Tribal EMS and University of New Mexico Health Sciences Center, Albuquerque, New Mexico (C.C.W.)
| | - Darren Braude
- University of New Mexico Health Sciences Center, Albuquerque, New Mexico (K.P., D.B.)
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Sinclair JE, Austin M, Froats M, Leduc S, Maloney J, Dionne R, Reed A, Vaillancourt C. Characteristics, Prehospital Management, and Outcomes in Patients Assessed for Hypoglycemia: Repeat Access to Prehospital or Emergency Care. PREHOSP EMERG CARE 2018; 23:364-376. [PMID: 30111210 DOI: 10.1080/10903127.2018.1504150] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
BACKGROUND In Ontario, Canada, there currently are no prehospital treat-and-release protocols and the safety of this practice remains unclear. We sought to describe the characteristics, management, and outcomes of patients with hypoglycemia treated by paramedics, and to determine the predictors of repeat access to prehospital or emergency department (ED) care within 72 hours of initial paramedic assessment. METHODS We performed a health record review of paramedic call reports and ED records over a 12-month period. We queried prehospital databases to identify cases, which included all adult patients (≥ 18 years) with a prehospital glucose reading of <72mg/dl (4.0mmol/L) and excluded terminally ill and cardiac arrest patients. We developed and piloted a standardized data collection tool and obtained consensus on all data definitions before initiation of data extraction by trained investigators. Data analyses include descriptive statistics with standard deviations, Chi-square, t-tests, and logistic regression with adjusted odds ratios (AdjOR). RESULTS There were 791 patients with the following characteristics: mean age 56.2, male 52.3%, known diabetic 61.6%, on insulin 46.1%, mean initial glucose 50.0 dl/mg (2.8 mmol/L), from home 56.3%. They were treated by an Advanced Care Paramedic 80.1%, received IV D50W 38.0%, IM glucagon 18.3%, PO complex carbs 26.6%, and accepted transport to hospital 69.4%. Of those transported, 134/556 (24.3%) were admitted and 9 (1.6%) died in the ED. Overall, 43 patients (5.4%) had repeat access to prehospital/ED care, among those, 8 (18.6%) were related to hypoglycemia. Patients on insulin were less likely to have repeat access to prehospital/ED care (AdjOR 0.4; 95%CI 0.2-0.9). This was not impacted by initial (or refusal of) transport (AdjOR 1.1; 95%CI 0.5-2.4). CONCLUSION Although risk of repeat access to prehospital/ED care for patients with hypoglycemia exists, it was less common among patients taking insulin and was not predicted by an initial refusal of transport.
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Sanello A, Gausche-Hill M, Mulkerin W, Sporer KA, Brown JF, Koenig KL, Rudnick EM, Salvucci AA, Gilbert GH. Altered Mental Status: Current Evidence-based Recommendations for Prehospital Care. West J Emerg Med 2018; 19:527-541. [PMID: 29760852 PMCID: PMC5942021 DOI: 10.5811/westjem.2018.1.36559] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 11/15/2017] [Accepted: 01/04/2018] [Indexed: 12/11/2022] Open
Abstract
Introduction 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. Methods 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. Results 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. Conclusion 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.
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Affiliation(s)
- Ashley Sanello
- Los Angeles County Emergency Medical Services (EMS) Agency, Santa Fe Springs, California.,David Geffen School of Medicine, Department of Emergency Medicine, Los Angeles, California
| | - Marianne Gausche-Hill
- Los Angeles County Emergency Medical Services (EMS) Agency, Santa Fe Springs, California.,Harbor UCLA, Department of Emergency Medicine, Torrance, California.,David Geffen School of Medicine, Department of Emergency Medicine, Los Angeles, California.,EMS Medical Directors Association of California
| | - William Mulkerin
- Stanford University, Department of Emergency Medicine, Stanford, California
| | - Karl A Sporer
- University of California, San Francisco, Department of Emergency Medicine, San Francisco, California.,EMS Medical Directors Association of California
| | - John F Brown
- University of California, San Francisco, Department of Emergency Medicine, San Francisco, California.,EMS Medical Directors Association of California
| | - Kristi L Koenig
- EMS Medical Directors Association of California.,County of San Diego, Health & Human Services Agency, Emergency Medical Services, San Diego, California.,University of California, Irvine, Department of Emergency Medicine, Orange, California
| | - Eric M Rudnick
- EMS Medical Directors Association of California.,NorCal EMS Agency, Redding, California
| | - Angelo A Salvucci
- EMS Medical Directors Association of California.,Ventura County EMS Agency, Oxnard, California
| | - Gregory H Gilbert
- EMS Medical Directors Association of California.,Stanford University, Department of Emergency Medicine, Stanford, California
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How do EMS medical directors think? Am J Emerg Med 2017; 35:1376-1378. [DOI: 10.1016/j.ajem.2017.03.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Revised: 03/23/2017] [Accepted: 03/23/2017] [Indexed: 11/21/2022] Open
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Villani M, de Courten B, Zoungas S. Emergency treatment of hypoglycaemia: a guideline and evidence review. Diabet Med 2017; 34:1205-1211. [PMID: 28477413 DOI: 10.1111/dme.13379] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/03/2017] [Indexed: 12/30/2022]
Abstract
AIM To examine the current treatment guidelines for the emergency management of hypoglycaemia and the evidence underpinning recommendations. METHODS International diabetes agencies were searched for hypoglycaemia treatment guidelines. Guidelines were assessed using the Appraisal of Guidelines Research and Evaluation II (AGREE II) instrument. An electronic database search was conducted for evidence regarding emergency treatment of hypoglycaemia in adults, and relevant articles were critically appraised. RESULTS Of the international diabetes agencies, six sets of guidelines were deemed relevant and of sufficient detail for appraisal by AGREE II. The evidence search returned 2649 articles, of which 17 pertaining to the emergency management of hypoglycaemia were included. High-quality evidence for the management of hypoglycaemia was lacking, limiting treatment recommendations. In general, guidelines and studies were somewhat concordant and recommended 15-20 g of oral glucose or sucrose, repeated after 10-15 min for treatment of the responsive adult, and 10% intravenous dextrose or 1 mg intramuscular glucagon for treatment of the unresponsive adult. No evidence was found for other treatment approaches. CONCLUSION Evidence for the emergency treatment of hypoglycaemia in adults is limited, is often low grade and mostly pre-dates contemporary management of diabetes. Guideline recommendations are limited by the lack of randomized trials. Further high-quality studies are required to inform the optimum management of this frequently occurring emergency condition.
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Affiliation(s)
- M Villani
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University in partnership with Monash Health, Clayton, VIC, Australia
| | - B de Courten
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University in partnership with Monash Health, Clayton, VIC, Australia
- Diabetes and Vascular Medicine Unit, Monash Health, Clayton, VIC, Australia
| | - S Zoungas
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University in partnership with Monash Health, Clayton, VIC, Australia
- Diabetes and Vascular Medicine Unit, Monash Health, Clayton, VIC, Australia
- The George Institute for Global Health, Camperdown, NSW, Australia
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Moffet HH, Warton EM, Siegel L, Sporer K, Lipska KJ, Karter AJ. Hypoglycemia Patients and Transport by EMS in Alameda County, 2013-15. PREHOSP EMERG CARE 2017. [PMID: 28641035 DOI: 10.1080/10903127.2017.1321707] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To estimate the rate, characteristics, and dispositions of hypoglycemia events among persons who received care from Alameda County, California, Emergency Medical Services (EMS). METHODS This study was based on data for 601,077 Alameda County EMS encounters during 2013-15. Subjects were defined as having hypoglycemia if EMS personnel recorded a primary impression of hypoglycemia or low blood glucose (<60 mg/dl or "unspecified low"). The outcome of interest was patient transport or non-transport to an emergency department or other care setting; we excluded 33,177 (6%) encounters which lacked clear disposition outcomes. RESULTS Among 567,900 eligible encounters, 8,332 (1.47%) were attributed to hypoglycemia, of which 1,125 (13.5%) were not transported. Non-transport was more likely among males, adult patients age <60, initial blood glucose >60 mg/dl or EMS arrival time 18:00-6:00. CONCLUSIONS Without an understanding of EMS encounters and non-transport rates, surveillance based solely on emergency department and hospital data will significantly underestimate rates of severe hypoglycemia. Additionally, given that hypoglycemia is often safely and effectively treated by non-physicians, EMS protocols should provide guidance for non-transport of hypoglycemic patients whose blood glucose levels have normalized.
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Chinn M, Colella MR. Prehospital Dextrose Extravasation Causing Forearm Compartment Syndrome: A Case Report. PREHOSP EMERG CARE 2016; 21:79-82. [DOI: 10.1080/10903127.2016.1209263] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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