Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors
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Evidence-based guidelines that provide recommendations for clinical care or operations are increasingly being published to inform the EMS community. The quality of evidence evaluation and methodological rigor undertaken to develop and publish these recommendations vary. This can negatively affect dissemination, education, and implementation efforts. ⋯ In this special contribution, we aim to describe the current state of published guidelines available to the EMS community informed by two recent systematic reviews of existing prehospital evidenced based guidelines (EBGs). We further aim to provide a description of key elements of EBGs, methods that can be used to assess their quality, and concrete recommendations for guideline developers to improve the quality of evidence evaluation, guideline development, and reporting. Finally, we outline six key recommendations for improving prehospital EBGs, informed by systematic reviews of prehospital guidelines performed by the Prehospital Guidelines Consortium.
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Ketamine is an emerging alternative sedation agent for prehospital management of agitation, yet research is limited regarding its use for children. Our objective was to compare the effectiveness and safety of ketamine and benzodiazepines when used for emergent prehospital sedation of pediatric patients with behavioral emergencies. ⋯ In this pediatric cohort, prehospital sedation with ketamine was associated with greater patient improvement, less subsequent sedative administration, and greater sedation compared to benzodiazepines. Though we identified low rates of adverse events in both groups, ketamine was associated with more instances of marked sedation, which bears further study.
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Patients with severe traumatic brain injury (TBI) are commonly intubated during prehospital treatment despite a lack of evidence that this is beneficial. Accumulating evidence even suggests that prehospital intubation may be hazardous, in particular when performed by inexperienced EMS clinicians. To expand the limited knowledge base, we studied the relationship between prehospital intubation and hospital mortality in patients with severe TBI in a large Dutch trauma database. We specifically hypothesized that the relationship differs depending on whether a physician-based emergency medical service (EMS) was involved in the treatment, as opposed to intubation by paramedics. ⋯ The data do not support the common practice of prehospital intubation. The effect of prehospital intubation on mortality might depend on EMS clinician experience, and it seems prudent to involve prehospital personnel well proficient in prehospital intubation whenever intubation is potentially required. The decision to perform prehospital intubation should not merely be based on the largely unsupported dogma that it is generally needed in severe TBI, but should rather individually weigh potential benefits and harms.
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Heat stroke is a problem that occurs primarily in the out-of-hospital environment. "Cool first, transport second" has been emphasized in consensus statements and systematic reviews regarding the treatment of exertional heat stroke by both EMS and the sports medicine/athletic training communities. However, there remains little guidance on cooling recommendations for the out-of-hospital care of non-exertional heat stroke or classic heat stroke. There is no consensus on the safety or feasibility of cooling classic heat stroke patients in the out-of-hospital environment using cold-water immersion. This case series describes the successful application of on-scene cold-water immersion for five classic heat stroke patients guided by real-time core temperature monitoring.
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Historically, dispatch-directed cardiopulmonary resuscitation (CPR) protocols only allow chest compression instructions to be delivered for patients able to be placed in the traditional supine position. For patients who are unable to be positioned supine, the telecommunicator and caller have no option except to continue attempts to position supine, which may result in delayed or no chest compressions being delivered prior to emergency medical services arrival. Any delay or lack of bystander chest compressions may result in worsening clinical outcomes of out-of-hospital cardiac arrest (OHCA) victims. We present the first two cases, to the best of our knowledge, of successfully delivered, bystander-administered, prone CPR instructions by a trained telecommunicator for two OHCA victims unable to be positioned supine.