Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors
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To describe current prehospital airway management practices for adults and children and barriers to adoption of evidence-based airway management practices in California. ⋯ The results of our study suggest that in areas of EMS where robust evidence exists, medical directors (100%) will discontinue or not adopt skills that potentially harm patients, such as RSI, but are unlikely (12%) to discontinue procedures that show no benefit to patients (such as pediatric ETI). Barriers to adoption of evidence-based practice include difficulty in generalizing results of studies across diverse EMS systems and perceived lack of evidence that the procedure should be abandoned.
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Case Reports
Traumatic tension pneumocephalus after blunt head trauma and positive pressure ventilation.
Pneumocephalus following head trauma is relatively rare, with tension pneumocephalus occurring in an even smaller group of patients. This review presents a recent case of tension pneumocephalus following the use of a manually operated bag-valve-mask to assist ventilations prior to rapid-sequence intubation. A discussion of this case in terms of other reported cases of pneumocephalus after oxygen therapy follows. ⋯ The prehospital diagnosis of pneumocephalus is difficult, as the symptoms and mechanism of injury mimic those associated with intracranial hemorrhage. The use of mannitol in the prehospital treatment of this patient and subsequent improvement in pupillary response may indicate that mannitol has a role in the treatment of tension pneumocephalus when neurosurgical services are not readily available. Additional research is needed to better understand the benefits and risks associated with this treatment modality.
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Review Meta Analysis
A meta-analysis of prehospital airway control techniques part II: alternative airway devices and cricothyrotomy success rates.
Airway management is a key component of prehospital care for seriously ill and injured patients. Oral endotracheal intubation (OETI) is the definitive airway of choice in most emergency medical services (EMS) systems. However, OETI may not be an approved skill for some clinicians or may prove problematic in certain patients because of anatomic abnormalities, trauma, or inadequate relaxation. In these situations alternative airways are frequently employed. However, the reported success rates for these devices vary widely, and established benchmarks are lacking. ⋯ We provide pooled estimates for prehospital AAD, NCRIC, and SCRIC airway interventions. Of the AADs, the King LT demonstrated the highest insertion success rate (96.5%), although this estimate is based on limited data, and data regarding its ventilatory effectiveness are lacking; more data are available for the ETC and LMA. The ETC, LMA, and PTLA all had similar-but lower-success rates (82.1%-87.4%). NCRIC has a low rate of success (65.8%); SCRIC has a much higher success rate (90.5%) and should be considered the preferred percutaneous rescue airway.
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The elderly utilize emergency medical services (EMS) at a higher rate than younger patients, yet little is known about the influence of injury on subsequent EMS utilization and costs. ⋯ An injury hospitalization in the elderly serves as a sentinel marker for an abrupt increase in EMS utilization and costs, even after accounting for confounders.
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Return of spontaneous circulation (ROSC) occurs in 35.0 to 61.0% of emergency medical services (EMS)-treated out-of-hospital cardiac arrests (OHCAs); however, not all patients achieving ROSC survive to hospital arrival or discharge. Previous studies have estimated the incidence of some types of rearrest(RA) at 61.0 to 79.0%, and the electrocardiogram (ECG) waveform characteristics of prehospital RA rhythms have not been previously described. ⋯ In this sample, the incidence of RA was 38.0%. The most common type of RA was PEA. Shockability of first EMS rhythm was found to predict subsequent RA rhythm shockability.