30-year-old woman • progressive dyspnea and peripheral edema • 35th week of gestation with a history of mild preeclampsia • Dx?

► progressive dyspnea and peripheral edema ► 35th week of gestation with a history of mild preeclampsia.

Is prehospital blood glucose measurement necessary in suspected cerebrovascular accident patients?

The present study was completed to establish an epidemiologic database defining prehospital management of suspected cerebrovascular accidents (CVAs) with attention to blood glucose measurement, in the hope of developing recommendations for further treatment protocols. On review of 9495 paramedic run reports for the 24-month period from January 2001 through December 2002, from a low-volume urban emergency medical services system, 185 persons presented with CVA signs and/or symptoms. Data collected included patient chief complaint, neurologic examination, patient age, vital signs, ambulance field times, patient past medical history, and blood glucose measurement with resulting prehospital interventions, efficacy of interventions, and iatrogenic complications. Five persons (2.70%), all medication-controlled diabetics, were found to be hypoglycemic. After administration of intravenous dextrose 50% by rescue personnel, improvement in neurologic condition was noted in 100% of these cases. No sequelae as a result of such care occurred. No inappropriate use, point estimate ([0]/[5][0.00%-52.20%]), or unmet need, point estimate ([0]/[9495][0.00%-0.04%]), of care was noted. The data presented in this study suggest that given similar emergency medical service system characteristics, hypoglycemic patients presenting with neurologic deficits suggestive of CVAs constitute a rare event, associated with medical histories predictive of problems involving glucose homeostasis. Blood glucose measurement in persons presenting with CVA signs and/or symptoms is only necessary given the presence of history suspicious for hypoglycemia, or rescuer inability to obtain adequate patient information. Routine prehospital blood glucose measurement in patients with suspected CVA appears unnecessary.

Prehospital midthigh trauma and traction splint use: recommendations for treatment protocols

The present study was completed to establish an epidemiologic database defining the prehospital occurrence of midthigh trauma/suspected femoral shaft fractures, and the use of/need for traction splints (TS) in hope of developing recommendations for further treatment protocols. On review of 4,513 paramedic run reports for the 12-month period from January 1999 through December 1999, from a low-volume urban emergency medical services (EMS) system, 16 persons (0.35% total patients) presented with midthigh injuries. Data collected included patient chief complaint/injury, mechanism of injury, clinical findings, splint application, additional interventions, iatrogenic complications, patient age, and ambulance field time. Paramedics noted injuries suspicious for femoral shaft fractures in 5 patients (31.25% study patients, 0.11% total patients). TSs were applied successfully only twice (12.50% study patients, 0.04% total patients). Fourteen patients (87.50% study patients) were managed with long backboard immobilization, rigid splinting, and/or patient transportation in a position of comfort. No sequelae as a result of such care occurred. No inappropriate use, point estimate (PE) [(0)/(16) (0.00% to 20.60%)] or unmet need, PE [(0)/(4), 497) (0.00% to 0.08%)] of care was noted. The data presented in this study suggest that given similar EMS system characteristics, prehospital midthigh injuries/suspected femoral shaft fractures occur on an extremely rare basis, and treatment with long backboard immobilization, rigid splinting, and/or patient transportation in a position of comfort may constitute an acceptable course of care. Including TSs as essential ambulance equipment may be unnecessary.

Prehospital management of rapid atrial fibrillation: recommendations for treatment protocols

The present study was completed to establish an epidemiological database defining prehospital rapid atrial fibrillation (RAF) and interventions given such patients in the hope of developing recommendations for further treatment protocols. On review of 4,749 paramedic run reports from a low-volume urban emergency medical services (EMS) system, 33 persons (0.69%) presented with RAF. Data collected included vital signs/ventricular rate, patient age, ambulance field times, patient chief complaint, prehospital interventions, efficacy of interventions, additional cardiac rhythms, iatrogenic complications, and patient past medical history. Neither intravenous (IV) diltiazem or electrical cardioversion were used within the 12-month period of this study. Symptomatic/supportive care consisting of observation (72.73%) and interventions (27.27%) with nitroglycerine, furosemide, aspirin, morphine, and/or IV fluid bolus therapy accounted for all prehospital treatment. Paramedics documented improvement in 100% of patients. No cases occurred in which RAF resulted in severe hemodynamic instability. No inappropriate use, point estimate (PE) [(0)/(33) (0.00% to 10.60%)], or unmet need, PE [(0)/(4,716) (0.00% to 0.08%)] of care was noted. The data presented in this study suggest that given similar EMS system characteristics, prehospital RAF is an infrequently encountered, predominantly hemodynamically stable cardiac arrhythmia, readily treatable with symptomatic/supportive care, and cautious observation. The prehospital application of adult advanced cardiac life support guidelines utilizing IV diltiazem and electrical cardioversion for the treatment of RAF may be unnecessary.

Prehospital pharmacotherapeutic interventions: recommendations for medication administration by EMT-A and EMT-I personnel

Because many communities lack prehospital advanced life support (ALS) services, increasing public access to such care is important. The present study was completed to establish an epidemiological database defining prehospital pharmacotherapeutic interventions by ALS rescue teams, in the hope of developing recommendations for medication administration by non-ALS personnel. Data were collected on 333 patients, including indication for pharmacotherapy, patient age, ambulance field time, route of medication administration, adverse effects of pharmacotherapy, efficacy of pharmacotherapy, additional ALS interventions, and patient medication/past medical history. Medications studied included albuterol nebulizer treatments (albuterol), aminophylline, amyl nitrite, atropine, bretylium tosylate, dexamethasone sodium phosphate, dextrose 50% (D-50), diazepam, diphenhydramine, dopamine, epinephrine 1 mg/1 mL, epinephrine 1 mg/10 mL, furosemide, glucagon, ipecac, isoproterenol, lidocaine, morphine sulfate, naloxone, nitroglycerin tablets (nitroglycerin), sodium bicarbonate, and verapamil. Albuterol, D-50, and nitroglycerin were used more often than other medications, accounting for total pharmacotherapeutic interventions for 228 persons (68.47% of total patients), including 100% of all pediatric patients. Partial pharmacological needs for an additional 20 patients also were satisfied by these agents. In all, albuterol, D-50, and nitroglycerin accounted for 250 of 395 total medication interventions (63.29%). No inappropriate use, point estimate [(0)/(333) (0.00% to 0.90%)], or unmet need, point estimate [(0)/(3,613) (0.00% to 0.08%)], of care was noted. When faced with communities lacking ALS rescue services, albuterol, D-50, and nitroglycerin are recommended for administration by emergency medical technician-ambulance and intermediate level rescuers, because of the high rate of use, relative ease of administration, and high benefit/low complication rates associated with these medications.

Prehospital seizure management: triage criteria for the advanced life support rescue team

The present study was completed to establish advanced life support (ALS) versus non-ALS triage criteria for use by ALS prehospital personnel when faced with the seizure patient, in the hope of more efficient use of ALS rescue teams. Preselected triage criteria for acuity of care based on neurological condition, vital signs, and concomitant illness/injury were tested against retrospective data (paramedic run reports) collected on 230 patients. Triage criteria sensitivity (SENS), specificity (SPEC), positive predictive value (PPV), and negative predictive value (NPV) were determined with a 95% confidence interval (CI). Point estimate of use/need of care was noted. ALS interventions were instituted in 58 patients (25%). In 57 of these cases, indication for and ALS intervention, were established on initial patient assessment (SENS, 98.28; 95% CI, 90.76 to 99.96). Of 173 patients requiring no ALS intervention on initial assessment, only 1 (0.58%) developed complications warranting ALS therapy during the course of prehospital care (SPEC, 100.00; 95% CI, 100.00 to 99.99; PPV, 100.00; 95% CI, 100.00 to 94.63; NPV, 99.42; 95% CI, 96.82 to 99.99). No inappropriate use, point estimate (PE) [(0)/(172) (0.00% to 0.01%)] or unmet need, PE [(0)/(58) (0.00% to 5.16%)] of care was noted. The data presented in this study suggest that given similar field times, after initial patient assessment by ALS personnel, it is reasonable and safe to triage seizure patients who do not require ALS intervention to non-ALS rescue teams for continuation of care and transportation.