Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors
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Case Reports
Prehospital Transfusion of Low-Titer O + Whole Blood for Severe Maternal Hemorrhage: A Case Report.
Introduction: Beginning in 2017, multiple stakeholders within the Southwest Texas Regional Advisory Council for Trauma collaborated to incorporate cold-stored low-titer O RhD-positive whole blood (LTO + WB) into all phases of their trauma system, including the prehospital phase of care. Although the program was initially focused on trauma resuscitation, it was expanded to included non-traumatic hemorrhagic shock patients that may benefit from whole blood resuscitation. ⋯ We believe this to be the first reported case of post-partum hemorrhage resuscitated out of hospital with whole blood. Discussion: This case highlights the potential benefits of a prehospital whole blood program as well as the controversy surrounding a LTO + WB program that includes females of childbearing age.
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Background: The American Heart Association recommends acquiring and interpreting prehospital electrocardiograms (ECG) for patients transported by Emergency Medical Services (EMS) to the emergency department with symptoms highly suspicious of acute coronary syndrome. If interpreted correctly, prehospital ECGs have the potential to improve early detection of ST-elevation myocardial infarction (STEMI) and inform prehospital activation of the cardiac catheterization laboratory, thus reducing total ischemic time and improving patient outcomes. Standardized protocols for prehospital ECG interpretation methods are lacking due to variations in EMS system design, training, and procedures. ⋯ All EMS systems had some paid versus non-paid EMS personnel and the majority (86%) had both basic and advanced life support capabilities. Conclusions: Most NC EMS systems had a paramedic only ECG interpretation or paramedic in combination with a computerized algorithm approach. Very few used a physician read approach following transmission, even in rural service areas.
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Objective: This study aimed to investigate the association between coronary angiography (CAG) with and without percutaneous coronary intervention (PCI) after out-of-hospital cardiac arrest (OHCA) and neurological recovery and to determine the influence of primary electrocardiogram or patient age on the effects of CAG. Methods: Adult patients with OHCA with cardiac etiology who were admitted to PCI-capable hospitals from 2016 to 2017 were enrolled in this study from the nationwide OHCA registry of Korea. Coronary intervention was categorized into three groups: No CAG, CAG without PCI, and CAG with PCI. ⋯ Interaction analysis showed that although the effect size differed according to patient characteristics, both CAG groups were associated with an increased likelihood of good neurological recovery, regardless of primary electrocardiogram and age group. In younger patients, CAG with PCI had greater outcome benefits than CAG without PCI (8.54 [4.31-16.95] vs. 4.10 [2.69-6.24]), whereas CAG without PCI had a larger effect size than CAG with PCI in elderly patients (4.46 [2.59-7.68] vs. 2.92 [1.80-4.73]) (p value for interaction 0.02). Conclusions: Post-resuscitation CAG with and without PCI are associated with better neurological recovery in patients with OHCA, regardless of primary electrocardiogram and patient age.
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Myocardial infarction (MI) is a rare complication of blunt chest trauma (BCT). We describe an extensive antero-lateral MI due to thrombosis of the left main stem coronary artery following a blow to the lower face and upper anterior chest during an industrial accident in a 52-year-old male. The patient presented with acute left ventricular failure. ⋯ We aim to highlight the importance of cardiac assessment in trauma scenarios particularly where patients are unable to report symptoms. Our patient sadly did not survive his injuries. This case describes MI following BCT from the initial prehospital presentation through to postmortem findings and adds to the limited literature on the pathological mechanisms underpinning this rare complication.
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Observational Study
Effect of Acute Stroke Care Regionalization on Intravenous Alteplase Use in Two Urban Counties.
Importance: Intravenous alteplase is an effective treatment for acute ischemic stroke and is significantly underutilized. It is known that stroke centers with accreditation are more likely to provide intravenous alteplase treatment, and therefore, policies that increase the number of certified stroke centers and the number of acute ischemic stroke patients routed to these centers may be beneficial. Objective: To determine whether increasing access to primary stroke centers (regionalization) led to an increase in intravenous alteplase use in acute ischemic stroke patients. ⋯ After regionalization of stroke care, intravenous alteplase increased two-fold in San Mateo County [adjusted RR 2.20, p = 0.003, 95% CI (1.31, 3.69)] but did not show any statistically significant change in Santa Clara County [adjusted RR 1.10, p = 0.55, 95% CI (0.80, 1.51)]. In the post-regionalization phase, when compared with Santa Clara County, we found that San Mateo County had greater change in paramedic stroke detection, higher number of transports to primary stroke centers and more frequent use of intravenous alteplase at stroke centers. Conclusions: Our findings suggest that greater post-regionalization improvements in San Mateo County contributed to significantly better county-level thrombolysis use than Santa Clara County.