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Hemorrhage remains the major cause of preventable death after trauma. Recent data suggest that earlier blood product administration may improve outcomes. The purpose of this study was to determine whether opportunities exist for blood product transfusion by ground Emergency Medical Services (EMS).

This was a single EMS agency retrospective study of ground and helicopter responses from January 1, 2011 through December 31, 2015 for adult trauma patients transported from the scene of injury who met predetermined hemodynamic (HD) parameters for potential transfusion (heart rate [HR]≥120 and/or systolic blood pressure [SBP]≤90).

A total of 7,900 scene trauma ground transports occurred during the study period. Of 420 patients meeting HD criteria for transfusion, 53 (12.6%) had a significant mechanism of injury (MOI). Outcome data were available for 51 patients; 17 received blood products during their emergency department (ED) resuscitation. The percentage of patients receiving blood products based upon HD criteria ranged from 1.0% (HR) to 5.9% (SBP) to 38.1% (HR+SBP). In all, 74 Helicopter EMS (HEMS) transports met HD criteria for blood transfusion, of which, 28 patients received prehospital blood transfusion. Statistically significant total patient care time differences were noted for both the HR and the SBP cohorts, with HEMS having longer time intervals; no statistically significant difference in mean total patient care time was noted in the HR+SBP cohort.

In this study population, HD parameters alone did not predict need for ED blood product administration. Despite longer transport times, only one-third of HEMS patients meeting HD criteria for blood administration received prehospital transfusion. While one-third of ground Advanced Life Support (ALS) transport patients manifesting HD compromise received blood products in the ED, this represented 0.2% of total trauma transports over the study period. Given complex logistical issues involved in prehospital blood product administration, opportunities for ground administration appear limited within the described system.

MixFM, ZielinskiMD, MyersLA, BernsKS, LukeA, StubbsJR, ZietlowSP, JenkinsDH, SztajnkrycerMD. Prehospital Blood Product Administration Opportunities in Ground Transport ALS EMS – A Descriptive Study.

Needle thoracostomy (NT) is a common prehospital intervention for patients in extremis or cardiac arrest due to trauma. The purpose of this study is to compare outcomes, efficacy, and complications after a change in policy related to NT in a four-county Emergency Medical Services (EMS) system with a catchment area of greater than 1.6 million people.

This is a before and after observational study of all patients who had NT performed in the Central California (USA) EMS system. The before, anterior midclavicular line (MCL) group consisted of all patients who underwent NT from May 7, 2007 through February 28, 2013. The after, midaxillary line (MAL) axillary group consisted of all patients who underwent NT from March 1, 2013 through January 30, 2016, after policy revisions changed the timing, needle size, and placement location for NT. All prehospital and hospital records where NT was performed were queried for demographics, mechanism of injury, initial status and post-NT clinical change, reported complications, and final outcome. The trauma registry was accessed to obtain Injury Severity Scores (ISS). Information was manually abstracted by study investigators and examined utilizing univariate and multivariate analyses.

Three-hundred and five trauma patients treated with NT were included in this study, of which, 169 patients (the MCL group) were treated with a 14-guage intravenous (IV) catheter at least 5.0-cm long at the second intercostal space (ICS), MCL after being placed in the ambulance; and 136 patients (the MAL group) were treated with a 10-guage IV catheter at least 9.5-cm long at the fifth ICS, MAL on scene. The mean ISS was lower in the MAL cohort (64.5 versus 69.2; P=.007). The mortality rate was 79% in both groups. The multivariate model with regard to survival supported that a lower ISS (P<.001) and reported clinical change after NT (P=.003) were significant indicators of survival. No complications from NT were reported.

Changing the timing, length of needle, and location of placement did not change mortality in patients requiring NT. Needle thoracostomy was used more frequently after the change in policy, and the MAL cohort was less injured. No increase in reported complications was noted.

WeichenthalLA, OwenS, StrohG, RamosJ. Needle Thoracostomy: Does Changing Needle Length and Location Change Patient Outcome?

Mass-casualty incidents (MCIs) easily overwhelm a health care facility’s human and material resources through the extraordinary influx of casualties. Efficient and accurate triage of incoming casualties is a critical step in the hospital disaster response.

Traditionally, triage during MCIs has been manually performed using paper cards. This study investigated the use of electronic Simple Triage and Rapid Treatment (START) triage as compared to the manual method.

This observational, crossover study was performed during a live MCI simulation at an urban, Canadian, Level 1 trauma center on May 26, 2016. Health care providers (two medical doctors [MDs], two paramedics [PMs], and two registered nurses [RNs]) each triaged a total of 30 simulated patients - 15 by manual (paper-based) and 15 by electronic (computer-based) START triage. Accuracy of triage categories and time of triage were analyzed. Post-simulation, patients and participating health care providers also completed a feedback form.

There was no difference in accuracy of triage between the electronic and manual methods overall, 83% and 80% (P=1.0), between providers or between triage categories. On average, triage time using the manual method was estimated to be 8.4 seconds faster (P<.001) for PMs; and while small differences in triage times were observed for MDs and RNs, they were not significant. Data from the participant feedback survey showed that the electronic method was preferred by most health care providers. Patients had no preference for either method. However, patients perceived the computer-based method as “less personal” than the manual triage method, but they also perceived the former as “better organized.”

Hospital-based electronic START triage had the same accuracy as hospital-based manual START triage, regardless of triage provider type or acuity of patient presentations. Time of triage results suggest that speed may be related to provider familiarity with a modality rather than the modality itself. Finally, according to patient and provider perceptions, electronic triage is a feasible modality for hospital triage of mass casualties. Further studies are required to assess the performance of electronic hospital triage, in the context of a rapid surge of patients, and should consider additional efficiencies built in to electronic triage systems. This study presents a framework for assessing the accuracy, triage time, and feasibility of digital technologies in live simulation training or actual MCIs.

BolducC, MaghrabyN, FokP, LuongTM, HomierV. Comparison of Electronic Versus Manual Mass-Casualty Incident Triage.

Advances in emergency medicine research can be slow to make their way into clinical care, and implementing a new evidence-based intervention can be challenging in the emergency department. The Canadian Association of Emergency Physicians (CAEP) Knowledge Translation Symposium working group set out to produce recommendations for best practice in the implementation of a new science in Canadian emergency departments.

A systematic review of implementation strategies to change health care provider behaviour in the emergency department was conducted simultaneously with a national survey of emergency physician experience. We summarized our findings into a list of draft recommendations that were presented at the national CAEP Conference 2017 and further refined based on feedback through social media strategies.

We produced 10 recommendations for implementing new evidence-based interventions in the emergency department, which cover identifying a practice gap, evaluating the evidence, planning the intervention strategy, monitoring, providing feedback during implementation, and desired qualities of future implementation research.

We present recommendations to guide future emergency department implementation initiatives. There is a need for robust and well-designed implementation research to guide future emergency department implementation initiatives.

Does the analgesic effect of intravenous ketorolac differ if given in doses of 10, 15, or 30 mg to patients presenting to the emergency department with acute pain?

Motov S, Yasavolian M, Likourezos A, et al. Comparison of intravenous ketorolac at three single-dose regimens for treating acute pain in the emergency department: a randomized controlled trial. Ann Emerg Med 2017;70(2):177-84.

The History, Electrocardiogram (ECG), Age, Risk Factors, and Troponin (HEART) score is a decision aid designed to risk stratify emergency department (ED) patients with acute chest pain. It has been validated for ED use, but it has yet to be evaluated in a prehospital setting.

A prehospital modified HEART score can predict major adverse cardiac events (MACE) among undifferentiated chest pain patients transported to the ED.

A retrospective cohort study of patients with chest pain transported by two county-based Emergency Medical Service (EMS) agencies to a tertiary care center was conducted. Adults without ST-elevation myocardial infarction (STEMI) were included. Inter-facility transfers and those without a prehospital 12-lead ECG or an ED troponin measurement were excluded. Modified HEART scores were calculated by study investigators using a standardized data collection tool for each patient. All MACE (death, myocardial infarction [MI], or coronary revascularization) were determined by record review at 30 days. The sensitivity and negative predictive values (NPVs) for MACE at 30 days were calculated.

Over the study period, 794 patients met inclusion criteria. A MACE at 30 days was present in 10.7% (85/794) of patients with 12 deaths (1.5%), 66 MIs (8.3%), and 12 coronary revascularizations without MI (1.5%). The modified HEART score identified 33.2% (264/794) of patients as low risk. Among low-risk patients, 1.9% (5/264) had MACE (two MIs and three revascularizations without MI). The sensitivity and NPV for 30-day MACE was 94.1% (95% CI, 86.8-98.1) and 98.1% (95% CI, 95.6-99.4), respectively.

Prehospital modified HEART scores have a high NPV for MACE at 30 days. A study in which prehospital providers prospectively apply this decision aid is warranted.

Stopyra JP , Harper WS , Higgins TJ , Prokesova JV , Winslow JE , Nelson RD , Alson RL , Davis CA , Russell GB , Miller CD , Mahler SA . Prehospital Modified HEART Score Predictive of 30-Day Adverse Cardiac Events. Prehosp Disaster Med. 2018;33(1):58–62.

Prehospital point-of-care lactate (pLA) measurement may be a useful tool to assist paramedics with diagnosing a range of conditions, but only if it can be shown to be a reliable surrogate for serum lactate (sLA) measurement. The aim of this study was to determine whether pLA is a reliable predictor of sLA.

This was a retrospective study of adult patients over a 12-month period who had pLA measured by paramedics in an urban Australian setting and were transported by ambulance to a tertiary hospital where sLA was measured. Patients were excluded if they suffered a cardiopulmonary arrest at any time, had missing data, or if sLA was not measured within 24 hours of arrival. Levels of agreement were determined using methods proposed by Bland and Altman.

A total of 290 patients were transported with a pLA recorded. After exclusions, there were 155 patients (55.0% male; age 71 [SD=18] years) remaining who had sLA recorded within 24 hours. Elevated pLA (>2.0mMol/L) was associated with sLA measurement (76.1% vs 23.9%; OR 3.18; 95% CI, 1.88-5.37; P<.0001). Median time between measurements was 89 minutes (IQR=75). Overall, median pLA was higher than sLA (3.0 [IQR=2.0] mMol/L vs 1.7 [IQR=1.3]; P<.001). Bland-Altman analysis on all participants showed a mean difference of 1.48 mMol/L (95% CI, -3.34 to 6.31). Normal pLA was found to be a true negative in 82.9% of cases, and elevated pLA was a true positive in 48.3% of cases. When the time between measurements was less than 60 minutes (n=25), normal pLA predicted normal sLA with 100% accuracy, with a false-positive rate of 18.2%. As time between measurements increased, accuracy diminished and the false-positive rate increased.

Overall, the level of agreement between pLA and sLA was poor. Accuracy of pLA diminished markedly as the time between the two measurements increased. It may be possible to use pLA as a screening tool; when considered this way, pLA performed much better, though larger prospective trials would be needed to confirm this.

Swan KL , Keene T , Avard BJ . A 12-Month Clinical Audit Comparing Point-of-Care Lactate Measurements Tested by Paramedics with In-Hospital Serum Lactate Measurements. Prehosp Disaster Med. 2018;33(1):36–42.

The use of palliative care (PC) screening criteria to trigger PC consultations may optimize the utilization of PC services, improve patient comfort, and reduce invasive and futile end-of-life care. The aim of the present study was to assess the criterion validity and inter-rater reliability of a PC screening tool for patients admitted to an emergency department intensive care unit (ED-ICU).

Observational retrospective study evaluating PC screening criteria based on the presence of advanced diagnosis and the use of two “surprise questions” (traditional and modified). Patients were classified at ED-ICU admission in four categories according to the proposed algorithm.

A total of 510 patients were included in the analysis. From these, 337 (66.1%) were category 1, 0 (0.0%) category 2, 63 (12.4%) category 3, and 110 (21.6%) category 4. Severity of illness (Simplified Acute Physiology Score III score and mechanical ventilation), mortality (ED-ICU and intrahospital), and PC-related measures (order for a PC consultation, time between admission and PC consultation, and transfer to a PC bed) were significantly different across groups, more evidently between categories 4 and 1. Category 3 patients presented similar outcomes to patients in category 1 for severity of illness and mortality. However, category 3 patients had a PC consultation ordered more frequently than did category 1 patients. The screening criteria were assessed by two independent raters (n = 100), and a substantial interrater reliability was found, with 80% of agreement and a kappa coefficient of 0.75 (95% confidence interval = 0.62, 0.88).

This study is the first step toward the implementation of a PC screening tool in the ED-ICU. The tool was able to discriminate three groups of patients within a spectrum of increasing severity of illness, risk of death, and PC needs, presenting substantial inter-rater reliability. Future research should investigate the implementation of these screening criteria into routine practice of an ED-ICU.

Analysis of injuries during military operations has focused on those related to combat. Non-combat complaints have received less attention, despite the need for many troops to be evacuated for non-battle illnesses in Iraq. This study aims to further characterize the disease and non-battle injuries (DNBIs) seen at a tertiary combat hospital and to describe the types of procedures and medications used in the management of these cases.

In this observational study, patients were enrolled from a convenience sample with non-combat-related diseases and injuries who were evaluated in the emergency department (ED) of a US military tertiary hospital in Iraq from 2007-2008. The treating emergency physician (EP) used a data collection form to enroll patients that arrived to the ED whose injury or illness was unrelated to combat.

Data were gathered on 1,745 patients with a median age of 30 years; 84% of patients were male and 85% were US military personnel. The most common diagnoses evaluated in the ED were abdominal disorders, orthopedic injuries, and headache. Many cases involved intravenous access, laboratory testing, and radiographic testing. Procedures performed included electrocardiogram, lumbar puncture, and intubation.

Disease and non-battle traumatic injuries are common in a tertiary combat hospital. Emergency providers working in austere settings should have the diagnostic and procedural skills to evaluate and treat DNBIs.

Bebarta VS , Mora AG , Ng PC , Mason PE , Muck A , Maddry JK . Disease and Non-Battle Traumatic Injuries Evaluated by Emergency Physicians in a US Tertiary Combat Hospital. Prehosp Disaster Med. 2018;33(1):53–57.

Early recognition of an acute myocardial infarction (AMI) can increase the patient’s likelihood of survival. As the first point of contact for patients accessing medical care through emergency services, emergency medical dispatchers (EMDs) represent the earliest potential identification point for AMIs. The objective of the study was to determine how AMI cases were coded and prioritized at the dispatch point, and also to describe the distribution of these cases by patient age and gender.

No studies currently exist that describe the EMD’s ability to correctly triage AMIs into Advanced Life Support (ALS) response tiers.

The retrospective descriptive study utilized data from three sources: emergency medical dispatch, Emergency Medical Services (EMS), and emergency departments (EDs)/hospitals. The primary outcome measure was the distributions of AMI cases, as categorized by Chief Complaint Protocol, dispatch priority code and level, and patient age and gender. The EMS and ED/hospital data came from the Utah Department of Health (UDoH), Salt Lake City, Utah. Dispatch data came from two emergency communication centers covering the entirety of Salt Lake City and Salt Lake County, Utah.

Overall, 89.9% of all the AMIs (n=606) were coded in one of the three highest dispatch priority levels, all of which call for ALS response (called CHARLIE, DELTA, and ECHO in the studied system). The percentage of AMIs significantly increased for patients aged 35 years and older, and varied significantly by gender, dispatch level, and chief complaint. A total of 85.7% of all deaths occurred among patients aged 55 years and older, and 88.9% of the deaths were handled in the ALS-recommended priority levels.

Acute myocardial infarctions may present as a variety of clinical symptoms, and the study findings demonstrated that more than one-half were identified as having chief complaints of Chest Pain or Breathing Problems at the dispatch point, followed by Sick Person and Unconscious/Fainting. The 35-year age cutoff for assignment to higher priority levels is strongly supported. The Falls and Sick Person Protocols offer opportunities to capture atypical AMI presentations.

Clawson JJ , Gardett I , Scott G , Fivaz C , Barron T , Broadbent M , Olola C . Hospital-Confirmed Acute Myocardial Infarction: Prehospital Identification Using the Medical Priority Dispatch System. Prehosp Disaster Med. 2018;33(1):29–35.

The Delirium Drug Scale (DDS) is an evaluation scale developed to assess a patient's drug burden for delirium. The primary goal is to validate the association between the DDS score and the incidence of delirium.

This study was an observational retrospective cross-sectional chart review study in patients aged 75 years and older. It was carried out in three emergency departments of a tertiary care university health center. Patients were included if a medication list was available. Delirium present upon admission was assessed during the first five days of admission.

A total of 1,205 subjects were included in the analysis. The mean age was of 83.4 years, and 62.4% were female. The prevalence of delirium was 19.1%. A total of 745 patients (62%) were exposed to DDS medication. The relative risk for the low (1–2) and high (>2) exposure group according to the DDS score was of 1.26 (CI: 0.95; 1.66) and 2.18 (CI: 1.61; 2.96) compared to a score of 0. In the multivariate analysis, dementia, anxiety, insomnia, history of delirium, infection, and acute kidney failure were significantly associated to delirium. When adjusted for confounding variables, the DDS score was associated with the incidence of delirium with an odd ratio (OR) of 1.29 (CI: 1.16; 1.44).

This study found that DDS score was associated with delirium incidence. The association persisted in the multivariate analysis adjusted for 26 known risks and precipitating factors for delirium.

Atrial fibrillation (AF) is the most common arrhythmia presentation to the emergency department (ED) and frequently results in admission to the hospital. Although rarely life-threatening and not usually an emergent condition, AF places a large burden on our health-care system. The objective of this study was to describe the practices of ED physicians in the management of AF in a large urban Canadian city.

From January 1, 2010 to December 31, 2010, patients with a primary diagnosis of AF were identified across 10 EDs in Toronto, Canada (N=2,609). Fifty patients were selected at random from each hospital for a detailed chart review (n=500).

Two hundred thirty-two patients (46%) received rate control, and 129 (26%) received rhythm control with the remainder (28%) receiving neither therapy. Sixty-seven percent of patients were discharged home. Most patients (79%) were symptomatic on arrival; however, only a minority of these (31%) received rhythm control. Factors that were associated with rhythm control included younger age, duration of palpitations ≤ 48 hours, a lower CHADS2 score, and the absence of left ventricular dysfunction.

Our data suggest a wide range of practice amongst ED physicians treating patients presenting to the ED with a primary diagnosis of AF. A randomized trial is needed to better understand the optimal management strategy in this patient population and setting.

The goal of this study was to examine the mental health needs of children and youth who present to the emergency department (ED) for mental health care and to describe the type of, and satisfaction with, follow-up mental health services accessed.

A 6-month to 1.5-year prospective cohort study was conducted in three Canadian pediatric EDs and one general ED, with a 1-month follow-up post-ED discharge. Measures included 1) clinician rating of mental health needs, 2) patient and caregiver self-reports of follow-up services, and 3) interviews regarding follow-up satisfaction. Data analysis included descriptive statistics and the Fisher’s exact test to compare sites.

The cohort consisted of 373 children and youth (61.1% female; mean age 15.1 years, 1.5 standard deviation). The main reason for ED presentations was a mental health crisis. The three most frequent areas of need requiring action were mood (43.8%), suicide risk (37.4%), and parent-child relational problems (34.6%). During the ED visit, 21.6% of patients received medical clearance, 40.9% received a psychiatric consult, and 19.4% were admitted to inpatient psychiatric care. At the 1-month post-ED visit, 84.3% of patients/caregivers received mental health follow-up. Ratings of service recommendations were generally positive, as 60.9% of patients obtained the recommended follow-up care and 13.9% were wait-listed.

Children and youth and their families presenting to the ED with mental health needs had substantial clinical morbidity, were connected with services, were satisfied with their ED visit, and accessed follow-up care within 1-month with some variability.