Pre-hospital management protocols and perceived difficulty in diagnosing acute heart failure

Aim To illustrate the pre-hospital management arsenals and protocols in different EMS units, and to estimate the perceived difficulty of diagnosing suspected acute heart failure (AHF) compared with other common pre-hospital conditions. Methods and results A multinational survey included 104 emergency medical service (EMS) regions from 18 countries. Diagnostic and therapeutic arsenals related to AHF management were reported for each type of EMS unit. The prevalence and contents of management protocols for common medical conditions treated pre-hospitally was collected. The perceived difficulty of diagnosing AHF and other medical conditions by emergency medical dispatchers and EMS personnel was interrogated. Ultrasound devices and point-of-care testing were available in advanced life support and helicopter EMS units in fewer than 25% of EMS regions. AHF protocols were present in 80.8% of regions. Protocols for ST-elevation myocardial infarction, chest pain, and dyspnoea were present in 95.2, 80.8, and 76.0% of EMS regions, respectively. Protocolized diagnostic actions for AHF management included 12-lead electrocardiogram (92.1% of regions), ultrasound examination (16.0%), and point-of-care testings for troponin and BNP (6.0 and 3.5%). Therapeutic actions included supplementary oxygen (93.2%), non-invasive ventilation (80.7%), intravenous furosemide, opiates, nitroglycerine (69.0, 68.6, and 57.0%), and intubation 71.5%. Diagnosing suspected AHF was considered easy to moderate by EMS personnel and moderate to difficult by emergency medical dispatchers (without significant differences between de novo and decompensated heart failure). In both settings, diagnosis of suspected AHF was considered easier than pulmonary embolism and more difficult than ST-elevation myocardial infarction, asthma, and stroke. Conclusions The prevalence of AHF protocols is rather high but the contents seem to vary. Difficulty of diagnosing suspected AHF seems to be moderate compared with other pre-hospital conditions

Altitude-Related Change in Endotracheal Tube Cuff Pressures in Helicopter EMS

Introduction: Over-inflation of endotracheal tube (ETT) cuffs has the potential to lead to scarring and stenosis of the trachea. 1, 2, 3, 4 The air inside an ETT cuff is subject to expansion as atmospheric pressure decreases, as happens with an increase in altitude. Emergency medical services helicopters are not pressurized, thereby providing a good environment for studying the effects of altitude changes ETT cuff pressures. This study aims to explore the relationship between altitude and ETT cuff pressures in a helicopter air-medical transport program. Methods: ETT cuffs were initially inflated in a nonstandardized manner and then adjusted to a pressure of 25 cmH 2O. The pressure was again measured when the helicopter reached maximum altitude. A final pressure was recorded when the helicopter landed at the receiving facility. Results: We enrolled 60 subjects in the study. The mean for initial tube cuff pressures was 70 cmH 2O. Maximum altitude for the program ranged from 1,000–3,000 feet above sea level, with a change in altitude from 800–2,480 feet. Mean cuff pressure at altitude was 36.52 ± 8.56 cmH 2O. Despite the significant change in cuff pressure at maximum altitude, there was no relationship found between the maximum altitude and the cuff pressures measured. Conclusion: Our study failed to demonstrate the expected linear relationship between ETT cuff pressures and the maximum altitude achieved during typical air-medical transportation in our system. At altitudes less than 3,000 feet above sea level, the effect of altitude change on ETT pressure is minimal and does not require a change in practice to saline-filled cuffs

Altitude-Related Change in Endotracheal Tube Cuff Pressures in Helicopter EMS

Introduction: Over-inflation of endotracheal tube (ETT) cuffs has the potential to lead to scarring and stenosis of the trachea. 1, 2, 3, 4 The air inside an ETT cuff is subject to expansion as atmospheric pressure decreases, as happens with an increase in altitude. Emergency medical services helicopters are not pressurized, thereby providing a good environment for studying the effects of altitude changes ETT cuff pressures. This study aims to explore the relationship between altitude and ETT cuff pressures in a helicopter air-medical transport program. Methods: ETT cuffs were initially inflated in a nonstandardized manner and then adjusted to a pressure of 25 cmH 2O. The pressure was again measured when the helicopter reached maximum altitude. A final pressure was recorded when the helicopter landed at the receiving facility. Results: We enrolled 60 subjects in the study. The mean for initial tube cuff pressures was 70 cmH 2O. Maximum altitude for the program ranged from 1,000–3,000 feet above sea level, with a change in altitude from 800–2,480 feet. Mean cuff pressure at altitude was 36.52 ± 8.56 cmH 2O. Despite the significant change in cuff pressure at maximum altitude, there was no relationship found between the maximum altitude and the cuff pressures measured. Conclusion: Our study failed to demonstrate the expected linear relationship between ETT cuff pressures and the maximum altitude achieved during typical air-medical transportation in our system. At altitudes less than 3,000 feet above sea level, the effect of altitude change on ETT pressure is minimal and does not require a change in practice to saline-filled cuffs

Familial Anaphylaxis after Silkworm Ingestion

Herein, we present a case of anaphylaxis in multiple family members after ingesting silkworms, an Asian delicacy. While food allergies, including anaphylaxis are unfortunately common, there are no previous reports of multiple family members suffering an anaphylactic reaction after eating silkworms. In addition, both family members required multiple doses of epinephrine and eventually an epinephrine infusion to improve their blood pressures. All interventions, including the epinephrine infusions, were started by emergency medical services (EMS) with on-line medical direction. Both the reaction and the required treatment are not extensively documented in the medical literature

A Comparison of Non-Invasive Blood Pressure Measurement Strategies with Intra-Arterial Measurement

INTRODUCTION: It is difficult to obtain an accurate blood pressure (BP) measurement, especially in the prehospital environment. It is not known fully how various BP measurement techniques differ from one another. STUDY OBJECTIVE: The study hypothesized that there are differences in the accuracy of various non-invasive blood pressure (NIBP) measurement strategies as compared to the gold standard of intra-arterial (IA) measurement. METHODS: The study enrolled adult intensive care unit (ICU) patients with radial IA catheters placed to measure radial intra-arterial blood pressure (RIBP) as a part of their standard care at a large, urban, tertiary-care Level I trauma center. Systolic blood pressure (SBP) was taken by three different NIBP techniques (oscillometric, auscultated, and palpated) and compared to RIBP measurements. Data were analyzed using the paired t-test with dependent samples to detect differences between RIBP measurements and each NIBP method. The primary outcome was the difference in RIBP and NIBP measurement. There was also a predetermined subgroup analysis based on gender, body mass index (BMI), primary diagnosis requiring IA line placement, and current vasoactive medication use. RESULTS: Forty-four patients were enrolled to detect a predetermined clinically significant difference of 5mmHg in SBP. The patient population was 63.6% male and 36.4% female with an average age of 58.4 years old. The most common primary diagnoses were septic shock (47.7%), stroke (13.6%), and increased intracranial pressure (ICP; 13.6%). Most patients were receiving some form of sedation (63.4%), while 50.0% were receiving vasopressor medication and 31.8% were receiving anti-hypertensive medication. When compared to RIBP values, only the palpated SBP values had a clinically significant difference (9.88mmHg less than RIBP; P \u3c .001). When compared to RIBP, the oscillometric and auscultated SBP readings showed statistically but not clinically significant lower values. The palpated method also showed a clinically significant lower SBP reading than the oscillometric method (5.48mmHg; P \u3c .001) and the auscultated method (5.06mmHg; P \u3c .001). There was no significant difference between the oscillometric and auscultated methods (0.42mmHg; P = .73). CONCLUSION: Overall, NIBPs significantly under-estimated RIBP measurements. Palpated BP measurements were consistently lower than RIBP, which was statistically and clinically significant. These results raise concern about the accuracy of palpated BP and its pervasive use in prehospital care. The data also suggested that auscultated and oscillometric BP may provide similar measurements

Measuring Agreement Among Prehospital Providers and Physicians in Patient Capacity Determination

OBJECTIVES: If a patient wishes to refuse treatment in the prehospital setting, prehospital providers and consulting emergency physicians must establish that the patient possesses the capacity to do so. The objective of this study is to assess agreement among prehospital providers and emergency physicians in performing patient capacity assessments. METHODS: This study involved 139 prehospital providers and 28 emergency medicine physicians. Study participants listened to 30 medical control calls pertaining to patient capacity and were asked to interpret whether the patients in the scenarios had the capacity to refuse treatment. Participants also reported their comfort level using modified Likert scales. Inter-rater reliability was calculated utilizing Fleiss\u27 and Model B kappa statistics. Fisher\u27s exact tests were used to calculate p-values comparing the proportion in each cohort that responded no capacity. Primary outcomes included inter-rater reliability in the physician and prehospital provider cohorts. RESULTS: The inter-rater agreement between the physicians was low (Fleiss\u27 kappa = 0.31, standard error [SE] =0.06; model-based kappa = 0.18, SE = 0.04). Agreement was similarly low for the 135 prehospital providers (Fleiss\u27 kappa = 0.30, SE = 0.06; model-based kappa = 0.28, SE = 0.04). The difference between the proportion of physicians and prehospital providers who responded no capacity was statistically significant in five of 30 scenarios. Median prehospital provider and physician confidence, on a 1 to 4 scale, was 2.00 (Q1-Q3 = 1.00-3.00 for prehospital providers and Q1-Q3 =1.0-2.0 for physicians). CONCLUSIONS: There was poor inter-rater reliability in capacity determination between and among the prehospital provider and physician cohorts. This suggests that there is need for additional study and standardization of this task