Faster refill in an urban emergency medical services system saves lives: A prospective preliminary evaluation of a prehospital advanced resuscitative care bundle

INTRODUCTION

Military experience has demonstrated mortality improvement when advanced resuscitative care (ARC) is provided for trauma patients with severe hemorrhage. The benefits of ARC for trauma in civilian emergency medical services (EMS) systems with short transport intervals are still unknown. We hypothesized that ARC implementation in an urban EMS system would reduce in-hospital mortality.

METHODS

This was a prospective analysis of ARC bundle administration between 2021 and 2023 in an urban EMS system with 70,000 annual responses. The ARC bundle consisted of calcium, tranexamic acid, and packed red blood cells via a rapid infuser. Advanced resuscitative care patients were compared with trauma registry controls from 2016 to 2019. Included were patients with a penetrating injury and systolic blood pressure ≤90 mm Hg. Excluded were isolated head trauma or prehospital cardiac arrest. In-hospital mortality was the primary outcome of interest.

RESULTS

A total of 210 patients (ARC, 61; controls, 149) met the criteria. The median age was 32 years, with no difference in demographics, initial systolic blood pressure or heart rate recorded by EMS, or New Injury Severity Score between groups. At hospital arrival, ARC patients had lower median heart rate and shock index than controls ( p ≤ 0.03). Fewer patients in the ARC group required prehospital advanced airway placement ( p < 0.001). Twenty-four-hour and total in-hospital mortality were lower in the ARC group ( p ≤ 0.04). Multivariable regression revealed an independent reduction in in-hospital mortality with ARC (odds ratio, 0.19; 95% confidence interval, 0.05-0.68; p = 0.01).

CONCLUSION

Early ARC in a fast-paced urban EMS system is achievable and may improve physiologic derangements while decreasing patient mortality. Advanced resuscitative care closer to the point of injury warrants consideration.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level IV.

Impact of a hypothetical COVID-19 vaccine mandate on parental likelihood to vaccinate children: Exploring school-related concerns and vaccination decision-making

OBJECTIVE

We assessed the impact of a hypothetical school-entry COVID-19 vaccine mandate on parental likelihood to vaccinate their child.

METHODS

We collected demographics, COVID-19-related school concerns, and parental likelihood to vaccinate their child from parents of patients aged 3-16 years seen across nine pediatric Emergency Departments from 06/07/2021 to 08/13/2021. Wilcoxon signed-rank test compared pre- and post-mandate vaccination likelihood. Multivariate linear and logistic regression analyses explored associations between parental concerns with baseline and change in vaccination likelihood, respectively.

RESULTS

Vaccination likelihood increased from 43% to 50% with a hypothetical vaccine mandate (Z = -6.69, p < 0.001), although most parents (63%) had no change, while 26% increased and 11% decreased their vaccination likelihood. Parent concerns about their child contracting COVID-19 was associated with greater baseline vaccination likelihood. No single school-related concern explained the increased vaccination likelihood with a mandate.

CONCLUSION

Parental school-related concerns did not drive changes in likelihood to vaccinate with a mandate.

Out-of-hospital cardiac arrest volumes and characteristics during the COVID-19 pandemic

AIM

The COVID-19 pandemic has significantly impacted Emergency Medical Services (EMS) operations throughout the country. Some studies described variation in total volume of out-of-hospital cardiac arrests (OHCA) during the pandemic. We aimed to describe the changes in volume and characteristics of OHCA patients and resuscitations in one urban EMS system.

METHODS

We performed a retrospective cohort analysis of all recorded atraumatic OHCA in Marion County, Indiana, from January 1, 2019 to June 30, 2019 and from January 1, 2020 to June 30, 2020. We described patient, arrest, EMS response, and survival characteristics. We performed paired and unpaired t-tests to evaluate the changes in those characteristics during COVID-19 as compared to the prior year. Data were matched by month to control for seasonal variation.

RESULTS

The total number of arrests increased from 884 in 2019 to 1034 in 2020 (p = 0.016). Comparing 2019 to 2020, there was little difference in age [median 62 (IQR 59-73) and 60 (IQR 47-72), p = 0.086], gender (38.5% and 39.8% female, p = 0.7466, witness to arrest (44.3% and 39.6%, p = 0.092), bystander AED use (10.1% and 11.4% p = 0.379), bystander CPR (48.7% and 51.4%, p = 0.242). Patients with a shockable initial rhythm (19.2% and 15.4%, p = 0.044) both decreased in 2020, and response time increased by 18 s [6.0 min (IQR 4.5-7.7) and 6.3 min (IQR 4.7-8.0), p = 0.008]. 47.7% and 54.8% (p = 0.001) of OHCA patients died in the field, 19.7% and 19.3% (p = 0.809) died in the Emergency Department, 21.8% and 18.5% (p = 0.044) died in the hospital, 10.8% and 7.4% (p = 0.012) were discharged from the hospital, and 9.3% and 5.9% (p = 0.005) were discharged with Cerebral Performance Category score ≤ 2.

CONCLUSION

Total OHCA increased during the COVID-19 pandemic when compared with the prior year. Although patient characteristics were similar, initial shockable rhythm, and proportion of patients who died in the hospital decreased during the pandemic. Further investigation will explore etiologies of those findings.

Supraventricular Tachycardia as the Initial Presentation of New-Onset Lupus: A Case Report

ABSTRACT

Systemic lupus erythematosus (SLE) is a chronic, autoimmune, multisystem disorder that can sometimes be life-threatening. The presentation varies widely given the wide range of clinical and serological manifestations coupled with the disease's ability to affect any organ. Prognosis depends on the organ systems involved, as well as the severity of the involvement. This case involves a 17-year-old with initial presentation of supraventricular tachycardia subsequently found to have pancreatitis, myocarditis, and nephritis secondary to a new diagnosis of SLE. Systemic lupus erythematosus can involve virtually any organ system, which leads to the variable nature of presentation, as was the case for our patient and his presentation being supraventricular tachycardia from underlying myocarditis secondary to SLE. Lupus myocarditis is rare, but when present often indicates severe systemic illness. The echocardiogram will often show global hypokinesis without evidence of coronary artery disease. This was the case with our patient. His echocardiogram demonstrated new-onset systolic left-sided heart failure due to nonischemic cardiomyopathy with an ejection fraction of 25%. Unfortunately for our patient, he had several poor prognostic factors on his initial presentation prior to any treatment being started, including renal disease, male, age (17 years), low socioeconomic status, African American race, and high disease activity. Systemic lupus erythematosus is the great mimicker and can present in a variety of ways. Given its ability to involve virtually any organ system, it is important to consider it on the differential diagnoses, especially in patients with a strong family history.

Modified Valsalva Maneuver for Pediatric Supraventricular Tachycardia

Vagal maneuvers can be successful in terminating supraventricular tachycardia in pediatric patients. We present a case of a modified Valsalva maneuver identified in the REVERT trial successfully terminating supraventricular tachycardia in a 9-year-old boy.

Pediatric Readiness in the Emergency Department

This is a revision of the previous joint Policy Statement titled "Guidelines for Care of Children in the Emergency Department." Children have unique physical and psychosocial needs that are heightened in the setting of serious or life-threatening emergencies. The majority of children who are ill and injured are brought to community hospital emergency departments (EDs) by virtue of proximity. It is therefore imperative that all EDs have the appropriate resources (medications, equipment, policies, and education) and capable staff to provide effective emergency care for children. In this Policy Statement, we outline the resources necessary for EDs to stand ready to care for children of all ages. These recommendations are consistent with the recommendations of the Institute of Medicine (now called the National Academy of Medicine) in its report "The Future of Emergency Care in the US Health System." Although resources within emergency and trauma care systems vary locally, regionally, and nationally, it is essential that ED staff, administrators, and medical directors seek to meet or exceed these recommendations to ensure that high-quality emergency care is available for all children. These updated recommendations are intended to serve as a resource for clinical and administrative leadership in EDs as they strive to improve their readiness for children of all ages.

Pediatric Medication Safety in the Emergency Department

Pediatric patients cared for in emergency departments (EDs) are at high risk of medication errors for a variety of reasons. A multidisciplinary panel was convened by the Emergency Medical Services for Children program and the American Academy of Pediatrics Committee on Pediatric Emergency Medicine to initiate a discussion on medication safety in the ED. Top opportunities identified to improve medication safety include using kilogram-only weight-based dosing, optimizing computerized physician order entry by using clinical decision support, developing a standard formulary for pediatric patients while limiting variability of medication concentrations, using pharmacist support within EDs, enhancing training of medical professionals, systematizing the dispensing and administration of medications within the ED, and addressing challenges for home medication administration before discharge.

Loop colostomies are totally diverting in adults

Temporary colostomy is a mainstay in the treatment of patients with colon injuries. Common teaching is that loop colostomies are not totally diverting. We performed this study to determine whether loop colostomies are totally diverting. Twenty-three patients presenting for closure of loop colostomies were given barium by mouth. Serial abdominal films were obtained at intervals over 24 hours. Scout films were obtained after bowel preparation to see if flushing the colon could cause passage of barium into distal bowel. We could not demonstrate passage of barium into the distal limb of the colon in any patient studied. This was true even in long-established loop colostomies. Bowel preparation did not cause passage of barium into the distal colon. Loop colostomies constructed over a rod and matured immediately totally divert the fecal stream. Most surgeons would agree that this type of colostomy is more easily and quickly created and closed. Since it fulfills the criteria for fecal diversion, the use of divided colostomies should be abandoned when a loop colostomy can be utilized.