Recurrent coagulopathy after antivenom treatment of crotalid snakebite

BACKGROUND

We studied whether recurrence of coagulopathy, defined as the return of a coagulation abnormality after initial normalization, occurred after the use of antivenin (Crotalidae) polyvalent.

METHODS

A retrospective, blinded, descriptive analysis of 354 consecutive cases of North American crotalid snake envenomation was done. Inclusion criteria were documented clinical evidence of crotalid snakebite, presence of a coagulopathy (platelet count <150,000/mm3, prothrombin time above normal, or fibrinogen level <150 mg/dL), and treatment with antivenin (Crotalidae) polyvalent.

RESULTS

Of 112 cases with a coagulopathy extending beyond 6 hours after envenomation, 31 had sufficient coagulopathy testing to detect recurrence. Fourteen of these patients (45%) had recurrence of coagulopathy, and two cases were severe (fibrinogen level 29 mg/dL; platelet count 36,000/mm3).

CONCLUSION

Recurrence of coagulopathy after envenomation by North American crotalid snakes may occur after use of antivenin (Crotalidae) polyvalent and can result in severe coagulation abnormalities.

Priorities for research in Emergency Medical Services for Children: results of a consensus conference. EMSC Research Agenda Consensus Committee, National EMSC Resource Alliance

STUDY OBJECTIVE

The study objective was to arrive at a consensus on the priorities for future research in Emergency Medical Services for Children (EMSC).

METHODS

A consensus group was convened using the Rand'-UCLA Consensus Process. The group took part in a 3-phase process. Phase I involved reviewing a compendium of relevant research articles and answering a mailed questionnaire. Panel members were asked to prioritize topics based on the 1993 Institute of Medicine Report on Emergency Medical Services for Children. Participants were asked to rate each topic based on the significance of the research and whether the topic would (1) improve general knowledge, (2) change behavior, (3) improve health, (4) decrease the cost of care, or (5) change public policy. A 4-point Likert scale was used. They were also asked in the research would require a multicenter study and if the research were feasible. Round II of the study involved a meeting of the panel, where the results of Round I were discussed and the topics reprioritized. The topics were given a rank order and a final ranking was done in Round III.

RESULTS

The panel considered a list of 32 topics and these were combined and reworded to give them more precise meaning. Several new topics were also added. Fifteen topics were given a rank order and placed within the 7 broad categories of the Institute of Medicine report. Clinical aspects of emergency care systems organization, configuration and operation and injury prevention were given high priority rankings. The first 5 topics were very close in point-rank order.

CONCLUSION

The panel was able to develop a list of important topics for future research in EMSC that can be used by foundations, governmental agencies, and others in setting a research agenda for EMSC.

Priorities for research in emergency medical services for children: results of a consensus conference

STUDY OBJECTIVE

To arrive at a consensus on the priorities for future research in emergency medical services for children.

METHODS

A consensus group was convened using the Rand-UCLA Consensus Process. The group took part in a 3-phase process. Round 1 involved reviewing a compendium of relevant research articles and answering a mailed questionnaire. Panel members were asked to prioritize topics on the basis of the 1993 Institute of Medicine Report on Emergency Medical Services for Children. Participants were asked to rate each topic based on the significance of the research, and whether the topic would (1) improve general knowledge, (2) change behavior, (3) improve health, (4) decrease the cost of care, or (5) change public policy. A 4-point Likert scale was used. Participants were also asked if the research would require a multicenter study and if the research were feasible. Round 2 of the study involved a meeting of the panel, where the results of Round 1 were discussed and the topics were reprioritized. The topics were given a rank order and a final ranking was done in Round 3.

RESULTS

The panel considered a list of 32 topics; these were combined and reworded to give them more precise meaning. Several new topics were also added. Fifteen topics were given a rank order and placed within the 7 broad categories of the Institute of Medicine report. Clinical aspects of emergency care, systems organization, configuration, and operation and injury prevention were given high priority rankings. The first 5 topics were very close in point-rank order.

CONCLUSION

The panel was able to develop a list of important topics for future research in emergency medical services for children that can be used by foundations, governmental agencies, and others in setting a research agenda for such services.

Priorities for research in emergency medical services for children: results of a consensus conference

OBJECTIVE

To arrive at a consensus on the priorities for future research in emergency medical services for children.

METHODS

A consensus group was convened using the Rand-UCLA Consensus Process. The group took part in a 3-phase process. Round I involved reviewing a compendium of relevant research articles and answering a mailed questionnaire. Panel members were asked to prioritize topics on the basis of the 1993 Institute of Medicine Report on Emergency Medical Services for Children. Participants were asked to rate each topic based on the significance of the research, and whether the topic would (1) improve general knowledge (2), change behavior (3), improve health (4), decrease the cost of care, or (5) change public policy. A 4-point Likert scale was used. Participants were also asked if the research would require a multicenter study and if the research were feasible. Round II of the study involved a meeting of the panel, where the results of Round I were discussed and the topics were reprioritized. The topics were given a rank order and a final ranking was done in Round III.

RESULTS

The panel considered a list of 32 topics; these were combined and reworded to give them more precise meaning. Several new topics were also added. Fifteen topics were given a rank order and placed within the 7 broad categories of the Institute of Medicine report. Clinical aspects of emergency care, systems organization, configuration, and operation and injury prevention were given high priority rankings. The first 5 topics were very close in point-rank order.

CONCLUSION

The panel was able to develop a list of important topics for future research in emergency medical services for children that can be used by foundations, governmental agencies, and others in setting research agenda for such services.

Uniform prehospital data elements and definitions: a report from the uniform prehospital emergency medical services data conference

One of the district and universal aspects of emergency medical service (EMS) is the belief that before its implementation many people were dying or being killed by ill-equipped, poorly trained "hearse drivers" and that this tragic state of affairs has been rectified by the advances in the prehospital phase of care. Except for cases of nontraumatic, out-of-hospital cardiac arrest there is almost no convincing scientific evidence to prove that prehospital care has had an impact on morbidity or mortality. At the very foundation of this problem is the lack of a set of broad-based, well-conceived, accurate, reliable, uniform EMS data. Many attempts have been made to develop a uniform EMS data set, but without a national consensus these have not achieved wide distribution. In 1992, with the assistance of the National Highway Traffic Safety Administration, the national consensus process began with a series of meetings involving many EMS agencies and organizations. This culminated in August 1994 with the development of an 81-item uniform EMS data set. We detail the prior attempts at data set development and outline the process leading to the this uniform, national EMS data set.

Cost-effectiveness analysis of paramedic emergency medical services in the treatment of prehospital cardiopulmonary arrest

STUDY OBJECTIVES

1) Identification of marginal costs associated with prehospital resuscitation of cardiopulmonary arrest; 2) Determination of cost effectiveness for such resuscitation; and 3) Comparison of cost effectiveness of paramedic care with selected other medical interventions.

DESIGN

Retrospective review of 190 cases of out-of-hospital cardiac arrest.

SETTING

City limits of a midsized southwestern city. The events studied took place outside of medical facilities.

TYPE OF PARTICIPANTS

Victims of out-of-hospital cardiac arrest for whom the EMS system was activated by a 911 telephone request for emergency medical assistance.

MEASUREMENTS AND MAIN RESULTS

The cost, including training, personnel, equipment, and response time maintenance, per year of life saved was found to be $8,886.00 for paramedic care. This result was compared with published cost-effectiveness figures for heart transplantation, liver transplantation, bone marrow transplantation, and chemotherapy for acute leukemia. Paramedic care was more cost effective, as measured by cost per year of life saved, than organ transplantation and chemotherapy for acute leukemia.

CONCLUSION

Out-of-hospital treatment by paramedics of cardiopulmonary arrest is more cost effective than heart, liver, bone marrow transplantation, or curative chemotherapy for acute leukemia.

Medical versus regulatory necessity: regulation of ambulance service in Arizona

Governmental regulation of emergency medical services and transportation differs from state to state. In Arizona, the Department of Health Services (ADHS) regulates the provision of ambulance service through a "certificate-of-necessity" (CON) process. Paramedic rescue services provided by municipalities are not, by statute, mandated to comply with these ADHS regulations. We review the way in which criteria for the determination of ambulance need were adopted by this state agency and the effects of their application in Tucson, Arizona. Approximately one million dollars and 5,500 unnecessary "code 3" (lights and siren activated) emergency vehicle trips were mandated by the ADHS need criteria, over a twelve-month period. We conclude that non-scientifically-derived regulatory criteria may conflict with prudent medical control of prehospital emergency medical services (EMS).

Railroad accidents: a metropolitan experience of death and injury

A review of all railroad-related deaths and significant injuries that occurred in a medium-sized metropolitan area from January 1, 1979, to June 30, 1986, was conducted. Autopsy reports were obtained for each fatality, and pre-hospital data were retrieved for all railroad-related injuries resulting in emergency medical services dispatch. There were ten fatalities (24%) and 31 survivors. The average age was 31.2 years (range, 1 to 67). Thirty-seven (90%) were men. Eleven persons (27%) were intoxicated (average blood alcohol of 279 mg/dL; range, 140 to 460). Of the 30 survivors transported, hospital records were available for 24. Thirteen were hospitalized and ten underwent surgery. Six major amputations occurred among survivors. Six patients had an Injury Severity Score of more than 15. Three mechanisms of injury occurred: falls on or from a train (56%); pedestrians hit by a train (41%), which accounted for all fatalities; and a train-automobile accident. This is the first comprehensive review of all significant railroad-related injuries in a metropolitan area.