Characteristics of Patients with an Abnormal Glasgow Coma Scale Score in the Prehospital Setting

Objective: This cross-sectional study describes the characteristics of patients with an abnormal Glasgow Coma Scale (GCS) in the prehospital setting.Methods: We reviewed existing prehospital care reports (PCRs) in the San Mateo County, California, emergency medical services (EMS) database from January 1 to December 31, 2007. Adults age 18 or greater with a documented GCS fit inclusion criteria. We excluded single and multisystem trauma patients, as well as patients in cardiac arrest, respiratory arrest, or listed as deceased from the study. We classified the remaining patients as a normal GCS of 15 or abnormal (defined as less than 15 at any time during paramedic contact), and then further sub-classified into mild (GCS 13-14), moderate (GCS 9-12) or severe (GCS 3-8).Results: Of the 12,235 unique prehospital care record in the database, 9,044 (73.9%) met inclusion criteria, comprised of 2,404 (26.6%) abnormal GCS patients and 6,640 (73.4%) normal GCS patients. In the abnormal GCS category, we classified 1,361 (56.6%) patients as mild, 628 (26.1%) as moderate, and 415 (17.3%) as severe. Where sex was recorded, we identified 1,214 (50.5%) abnormal GCS patients and 2,904 (43.7%) normal GCS patients as male. Mean age was 65.6 years in the abnormal GCS group and 61.4 in the normal GCS group (p<0.0001). Abnormal GCS patients were more likely to have a history of conditions known to be associated, such as alcohol abuse (odds ratio [OR] 2.3, 95% confidence interval [CI]=2.75-3.00), diabetes (OR 1.34, 95% CI=1.17-1.54), substance abuse (OR 1.6, CI=1.09-2.3), stroke/transient ischemic attack (OR 2.0, CI=1.64-2.5), and seizures (OR 3.0, CI=1.64-2.5). Paramedics established intravenous (IV) access on 1,821 (75.7%, OR 1.94, CI=1.74-2.2) abnormal GCS patients and administered medications to 777 (32.3%, OR 1.01, CI=0.92-1.12). Compared to patients with normal GCS, patients with a mildly abnormal GCS were less likely to receive medications (OR 0.61, CI=0.53-0.70) while those with a moderately or severely abnormal GCS were more likely (OR 1.27, CI=1.07-1.50 and OR 2.86, CI=2.34-3.49, respectively). Of the normal GCS patients, 4,097 (61.7%) received an IV and 2,125 (32.0%) received medications by any route.Conclusion: Twenty-seven percent of all prehospital patients in our study presented with an abnormal GCS. Prehospital patients with an abnormal GCS are more likely to be male, slightly older, and have higher rates of history of alcohol use or seizure. This group of patients had a higher rate of IV placement. Patients with a mildly abnormal GCS were less likely to receive medications while those with a moderately or severely abnormal GCS were more likely. [West J Emerg Med. 2011;12(1):30-36.

Detailed Analysis of Prehospital Interventions in Medical Priority Dispatch System Determinants

Background: Medical Priority Dispatch System (MPDS) is a type of Emergency Medical Dispatch (EMD) system used to prioritize 9-1-1 calls and optimize resource allocation. Dispatchers use a series of scripted questions to assign determinants to calls based on chief complaint and acuity.Objective: We analyzed the prehospital interventions performed on patients with MPDS determinants for breathing problems, chest pain, unknown problem (man down), seizures, fainting (unconscious) and falls for transport status and interventions.Methods: We matched all prehospital patients in complaint-based categories for breathing problems, chest pain, unknown problem (man down), seizures, fainting (unconscious) and falls from January 1, 2004, to December 31, 2006, with their prehospital record. Calls were queried for the following prehospital interventions: Basic Life Support care only, intravenous line placement only, medication given, procedures or non-transport. We defined Advanced Life Support (ALS) interventions as the administration of a medication or a procedure.Results: Of the 77,394 MPDS calls during this period, 31,318 (40%) patients met inclusion criteria. Breathing problems made up 12.2%, chest pain 6%, unknown problem 1.4%, seizures 3%, falls 9% and unconscious/fainting 9% of the total number of MPDS calls. Patients with breathing problem had a low rate of procedures (0.7%) and cardiac arrest medications (1.6%) with 38% receiving some medication. Chest pain patients had a similar distribution; procedures (0.5%), cardiac arrest medication (1.5%) and any medication (64%). Unknown problem: procedures (1%), cardiac arrest medication (1.3%), any medication (18%). Patients with Seizures had a low rate of procedures (1.1%) and cardiac arrest medications (0.6%) with 20% receiving some medication. Fall patients had a lower rate of severe illness with more medication, mostly morphine: procedures (0.2%), cardiac arrest medication (0.2%), all medications (28%). Unconscious/fainting patients received the following interventions: procedures (0.3%), cardiac arrest medication (1.9%), all medications (32%). Few stepwise increases in the rate of procedures or medications were seen as determinants increased in acuity.Conclusion: Among these common MPDS complaint-based categories, the rates of advanced procedures and cardiac arrest medications were low. ALS medications were common in all categories and most determinants. Multiple determinants were rarely used and did not show higher rates of interventions with increasing acuity. Many MPDS determinants are of modest use to predict ALS intervention. [West J Emerg Med. 2011;12(1):19-29.

Prehospital, post-ROSC blood pressure and associated neurologic outcome

ObjectiveTo investigate the relationship between hypotension and neurologic outcome in adults with return of spontaneous circulation after out-of-hospital cardiac arrest.MethodsBlood pressure and medication data were extracted from adult patients who had ROSC after OHCA in Alameda County and matched with neurologic outcome using the CARES database from January 1, 2018 through July 1, 2019. We used univariate logistic regression with p ≤ 0.2 followed by multivariate logistic regression and reported an odds ratio with 95% confidence intervals.ResultsAmong the 781 adult patients who had ROSC after OHCA, 107 (13.7%) were noted to be hypotensive and 61 (57% of the hypotensive group) received vasopressors. Patients with a final prehospital blood pressure recording of <90 mmHg were more likely to have a poor neurologic outcome (adjusted odds ratio 2.13, adj p = 0.048). About twice as many patients who were not hypotensive had a good neurologic outcome compared to hypotensive patients who had a good neurologic outcome (23% to 10.3%). Additionally, patients who were hypotensive and did not receive vasopressors had a similar neurologic outcome compared to patients who did receive vasopressors.ConclusionPrehospital post-ROSC hypotension was associated with worse neurologic outcome and giving hypotensive patients vasopressors may not improve neurologic outcome in the prehospital setting

911 Patient Redirection.

Sporer KA . 911 patient redirection. Prehosp Disaster Med. 2017;32(6):589-592

Buprenorphine: a primer for emergency physicians.

The recent approval of office-based treatment for opioid addiction and US Food and Drug Administration approval of buprenorphine will expand treatment options for opioid addiction. Buprenorphine is classified as a partial micro opioid agonist and a weak kappa antagonist. It has a high affinity for the micro receptor, with slow dissociation resulting in a long duration of action and an analgesic potency 25 to 40 times more potent than morphine. At higher doses, its agonist effects plateau and it begins to behave more like an antagonist, limiting the maximal analgesic effect and respiratory depression. This "ceiling effect" confers a high safety profile clinically, a low level of physical dependence, and only mild withdrawal symptoms on cessation after prolonged administration. Suboxone contains a mixture of buprenorphine and naloxone. The naloxone is poorly absorbed sublingually and is designed to discourage intravenous use. Subutex, buprenorphine only, will also be available primarily as an initial test dose. Clinicians will be using this drug for detoxification or for maintenance of opioid addiction. Patients with recent illicit opioid use may develop a mild precipitated withdrawal syndrome with the induction of buprenorphine. Acute buprenorphine intoxication may present with some diffuse mild mental status changes, mild to minimal respiratory depression, small but not pinpoint pupils, and relatively normal vital signs. Naloxone may improve respiratory depression but will have limited effect on other symptoms. Patients with significant symptoms related to buprenorphine should be admitted to the hospital for observation because symptoms will persist for 12 to 24 hours

911 Patient Redirection.

Sporer KA . 911 patient redirection. Prehosp Disaster Med. 2017;32(6):589-592