OBJECTIVES:Prehospital blood transfusion (PHBT) has been associated with reduced mortality for trauma patients in hemorrhagic shock. However, there are currently no standardized prehospital criteria to identify patients who may benefit from PHBT. We designed this study to assess the positive predictive value (PPV) of a set of PHBT criteria to identify patients requiring emergent transfusion within four hours of emergency department (ED) arrival. METHODS:We conducted an observational retrospective cohort study of all trauma patients ≥ 15 years-old who were transported by emergency medical services (EMS) between November 1st, 2021 and September 30th, 2023 to a trauma center prior to the implementation of PHBT protocols in LAC. We retrospectively applied the PHBT criteria: systolic blood pressure (SBP) < 70mmHg, a simultaneous reading of SBP < 90 mmHg and heart rate (HR) ≥ 110 beats per minute (BPM), or EMS-witnessed traumatic arrest. We excluded patients with cardiac arrest prior to EMS arrival, isolated head injury, or ground-level fall as the only mechanism of injury. Our primary outcome was the PPV of the PHBT criteria as a whole as well as each individual PHBT criterion for emergent transfusion need, which we defined as the proportion of trauma patients requiring in-hospital transfusion within four hours of ED arrival. RESULTS:Of the 25,473 trauma patients, 905 met one or more PHBT criterion with no exclusion. These patients were primarily male (76%, n = 688) with a median age of 35 (IQR 27-47) and most suffered blunt trauma (68%, n = 618). Overall, 475 (52%) received blood within four hours of hospital arrival. The PHBT criterion of SBP < 90 mmHg and HR ≥ 110 BPM was found to have the highest PPV (56%, 95% CI 52-60%) for in-hospital transfusion within four hours. PPV for the other PHBT criteria ranged between 51-53%. CONCLUSIONS:The PHBT criteria of SBP < 90 mmHg and HR ≥ 110 bpm had the greatest PPV for transfusion within four hours of ED arrival. This information may be used to further optimize criteria for PHBT and identify patients most likely to benefit.
Hemorrhage is a leading cause of preventable death after trauma, with direct pressure, appropriate tourniquet application, and volume resuscitation established as principles of hemorrhage management. In recent years, several junctional tourniquet devices have been proposed as adjuncts for groin and axillary hemorrhage control, including the Abdominal Aortic Junctional Tourniquet-Stabilized (AAJT-S), which has been marketed for non-compressible torso hemorrhage. To date, evidence supporting its use has been primarily limited to studies on cadavers, porcine models, healthy human subjects, and a few case reports. We present the case of a young adult male with multiple gunshot wounds to the pelvis and lower extremities who presented to a level I trauma center with an AAJT-S in place. Device removal in the trauma bay was followed by cardiac arrest and subsequent complications to include metabolic acidosis, compartment syndrome, rhabdomyolysis, renal and liver infarcts, pulmonary emboli, and stroke. This case highlights the potential harm of the device. We review and contrast these outcomes with the limited available literature and present our recommendation for future evaluation and caution with application of this device.
OBJECTIVES:Transfusing females of childbearing potential (FCP) in hemorrhagic shock with RhD-positive blood products risks inducing the formation of anti-D that can cause hemolytic disease of the fetus and newborn (HDFN) in future pregnancies. A previous study found that 957 FCPs were transfused with RhD-positive blood products over approximately 5-years in the United States (U.S.) in the prehospital phase of their resuscitation. This study used an in silico simulation to calculate the rate of future HDFN amongst these 957 transfused FCPs. METHODS:A model that calculated the overall risk of any severity of HDFN was updated with the most current nativity data in the U.S. population. The model first simulated 1,000 FCPs of unknown RhD type at each age between 12-50 years to determine their age-specific rate of future HDFN. This model was instantiated 500 times representing a total of 19.5 million simulated FCPs. The model then used the IQR of the median ages of the 957 transfused FCPs, stratified by U.S. geographic region, to simulate the future HDFN outcomes of these FCPs. This model was instantiated 500 times representing approximately 2,500 years. RESULTS:The maximum rate of HDFN for FCPs of unknown RhD type was approximately 0.8% and occurred when the FCPs were between ages 18-20 years. The risk of future HDFN for the 957 RhD-type unknown transfused FCPs ranged from 0.214% (Northeast) to 0.294% (South) per year. Over this 2,500 year simulation a total of 1,368 HDFN cases were calculated to occur (0.55 per year). The number of prehospital transfused FCPs was not equal between the geographic regions and ranged between 29 (Northeast) to 710 (South) every 5-years. Thus, based on the historical trends in these four geographic regions, one case of HDFN would be expected to occur every approximately 2.4- to 80.7-years depending on the geographic region. CONCLUSIONS:Due to the generally advanced maternal age of the 957 transfused FCPs and their low probability of being RhD-negative, the risk of future HDFN because of urgent prehospital RhD-positive transfusion is low.
OBJECTIVES:Much attention has been given to prehospital blood use for trauma, but evidence is lacking for non-traumatic hemorrhage. Therefore, we sought to evaluate the epidemiology of patients receiving prehospital whole blood for nontraumatic hemorrhage. METHODS:We conducted a retrospective observational study of patients receiving prehospital blood transfusions for non-traumatic hemorrhagic shock within two fire-based emergency medical services (EMS) systems, between February 20, 2024, and April 23, 2026. Patients were included if blood products were administered for a non-traumatic cause of hemorrhagic shock. Exclusion criteria included cardiac arrest and blood transfusion prior to EMS arrival. Data collected from electronic patient care records included demographics, scene type, blood product administered, operational time intervals, and physiologic parameters. Shock index was calculated at patient-level by dividing heart rate (HR) by systolic blood pressure (SBP) at initial EMS assessment, immediately prior to transfusion, and emergency department (ED) arrival. RESULTS:Of 163 blood transfusions, 50 (30.7%) were administered for non-traumatic hemorrhagic shock. After exclusions, 47 patients were included. Mean age was 66 years, and 55% were male. Gastrointestinal bleeding (GI) was the most common source (49%), followed by unspecified hemorrhagic shock (43%) and obstetric/gynecologic hemorrhage (4.3%). Most encounters occurred in private residences (57%) or rehabilitation/skilled nursing facilities (32%). Mean heart rate decreased from 102 at initial EMS assessment to 96 on ED arrival, while mean systolic blood pressure increased from 83 mmHg to 106 mmHg. Mean shock index decreased from 1.34 to 1.01. CONCLUSIONS:Our two-system observational study found just under a third of patients received blood for non-traumatic reasons, with the majority being for GI bleeding. Further work is needed to better understand the impact of blood for medical patients on patient outcomes.
OBJECTIVES:Obesity may impair the effectiveness of cardiopulmonary resuscitation (CPR) through biomechanical constraints; however, its impact on chest compression quality and the role of simple ergonomic modifications remain unclear. This study aimed to evaluate the effect of simulated obesity and body position on CPR performance. METHODS:This prospective randomized crossover simulation trial included 60 paramedics. Each participant performed 2-min chest compression sessions under three conditions: standard manikin, obesity-simulation manikin, and obesity-simulation manikin with the paramedic elevated on a 10 cm pad. Primary outcomes were compression depth, rate, and complete chest recoil. The secondary outcome was perceived exertion. Data were analyzed using linear mixed-effects models. The trial was prospectively registered (ACTRN12625000658415). RESULTS:Compression depth was significantly lower in both obesity-simulation conditions than in the standard condition, with adjusted mean differences of 17.83 mm (95% CI 15.95-19.71) and 18.44 mm (95% CI 16.58-20.30), respectively (both p < 0.001). The median percentage of compressions with adequate depth was 98.0% in the standard condition and 0.0% in both obesity-simulation conditions (both p < 0.001). Compression rate differed only modestly across conditions. Mean compression force and the Borg Rating of Perceived Exertion were significantly higher in obesity-simulation scenarios (both p < 0.001). No significant differences were observed between the two obesity-simulation conditions (difference 0.61 mm, 95% CI -1.25 to 2.47; p = 0.523), indicating that elevation of the paramedic did not improve CPR performance. CONCLUSIONS:Simulated obesity markedly impairs chest compression quality despite increased paramedics' effort, likely due to biomechanical constraints. The 10 cm elevation of the paramedic did not improve compression effectiveness. These findings highlight the need for targeted strategies and further prospective clinical studies to optimize CPR in patients with obesity.
OBJECTIVES:Capnometry is the gold standard for confirming endotracheal tube placement, yet the implementation in prehospital airway management remains inconsistent. This study aimed to investigate the use of capnometry during prehospital endotracheal intubation in Denmark, and to evaluate the association between capnometry use and 30-day mortality. METHODS:We conducted an observational study design with a nationwide retrospective registry-based cohort of prehospital endotracheal intubations in Denmark using data from January 1, 2016, to December 31, 2021. Data were obtained from the Danish Prehospital Medical Record system and linked to the Danish Civil Registration System for mortality outcomes. Capnometry use was defined as at least one recorded end-tidal carbon dioxide (EtCO₂) value >0. The primary outcome was capnometry use. Secondary outcomes included 30-day mortality and EtCO₂ values categorized as eucapnic (4.0-6.0 kPa), hypocapnic (<4.0 kPa), hypercapnic (>6.0 kPa). Associations with mortality were assessed using multivariable logistic regression adjusted for age, sex, symptom category, cardiopulmonary resuscitation, and time of day. RESULTS:A total of 8,720 intubations in 8,625 patients were identified, and only the first intubation per patient was included. Capnometry was used in 6,926 of 8,625 cases (80.3%) and increased from 75.4% in 2016 to 82.6% in 2021 (IRR 1.014, 95% CI 1.0004-1.0284; p = 0.04). Thirty-day mortality was 62.6%. Capnometry use was more frequent among survivors (87% vs. 76%, p < 0.001) and was independently associated with lower mortality (adjusted OR 0.52, 95% CI 0.46-0.60). Unadjusted 30-day mortality was higher for patients without capnometry use (74.8% vs. 59.6%; 1,270/1,699 vs. 4,131/6,926; p < 0.001). Abnormal EtCO₂ values were common: hypocapnic in 38.3%, hypercapnic in 19.0%, both in 22.6%, and only 10.1% had values within the normal range. Mortality was highest in patients with recorded hypocapnic values (70.4%; adjusted OR 2.67, 95% CI 2.20-3.24) and lowest in those with normal values (36.7%). CONCLUSIONS:Capnometry use during prehospital intubation increased over time but remained incomplete and was independently associated with lower 30-day mortality. Abnormal EtCO₂ values were frequent and associated with worse outcomes, particularly low EtCO₂ values. These findings support adherence to current recommendations for routine EtCO₂ monitoring in prehospital airway management.
OBJECTIVES:Out-of-hospital cardiac arrest (OHCA) has a high rate of mortality. While prehospital management of OHCA is well described, post-return of spontaneous circulation (ROSC) care in the prehospital setting is often based on in-hospital care and broadly lacks evidence-based prehospital-specific recommendations. Additionally, there are no formal standardized quality indicators to benchmark post-ROSC care in the prehospital setting. This study served to systematically identify and appraise post-ROSC documents to synthesize a set of potential quality indicators to inform the survey of a multi-stage Delphi consensus for national quality indicators for prehospital care after out-of-hospital cardiac arrest. METHODS:Following PRISMA guidelines, a systematic search was conducted across various databases for quality indicators and recommendations for prehospital care for post-ROSC following OHCA. Two reviewers performed title and abstract screening, full-text review, and quality appraisal using the Mixed Methods Appraisal Tool (MMAT) independently and in duplicate. Identified quality indicators and recommendations were extracted as potential quality indicators and categorized into functional domains by the research team. RESULTS:The search yielded 337 initial records, of which 87 underwent full-text review, and 46 studies met the a priori inclusion criteria. Studies from over 17 different countries were identified, of which the United States published the majority (n = 13). Randomized control trials represented the largest portion of the included studies (n = 18). The majority of study settings were in-hospital. Only five of the included studies made formal recommendations, and only two listed quality indicators. A total of 36 underwent appraisal with MMAT, of which the overall quality was generally high. A total of 16 potential quality indicators were extracted from the included studies and were grouped into five different domains. CONCLUSIONS:This focused scoping review highlights a lack of specific prehospital post-ROSC benchmarks and quality indicators. The identified potential quality indicators provide a foundational framework for a Delphi process for expert consensus on specific and measurable quality indicators. These indicators aim to standardize prehospital post-ROSC care for OHCA for national datasets like the Cardiac Arrest Registry to Enhance Survival.
OBJECTIVES:The COVID-19 pandemic disrupted traditional continuing education (CE) delivery methods, necessitating rapid adaptation to alternative educational formats. The pandemic led the National Registry of Emergency Medical Technicians (NREMT) to waive limitations on asynchronous online distributive learning (ADL) for emergency medical services (EMS) recertification. The Commission on Accreditation for Prehospital Continuing Education (CAPCE) maintains one of the largest EMS CE databases in the United States. The goal of this study was to examine trends in CAPCE-accredited EMS CE course formats over the past decade. METHODS:Five education formats were analyzed: live in-person, card-bearing courses, asynchronous online distributive learning, interactive gaming-style courses, and virtual instructor-led training. An observational retrospective interrupted time-series analysis was conducted using 19,289,785 EMS continuing education completions from the CAPCE database, from July 2014 through June 2024 (120 months). The COVID-19 intervention period was August 2020 through September 2022. Negative binomial regression and interrupted time-series models were used to estimate changes in course completions by CE format. RESULTS:Comparing mean monthly course completions between the pre-pandemic and post-pandemic periods, course format use shifted significantly. Live in-person courses decreased by 8.1%, from 3,324 to 3,053, while card-bearing courses increased by 15.1%, from 7,469 to 8,598. In contrast, online formats all saw large increases: asynchronous online distributive learning courses increased by 209.4%, from 86,242 to 266,842, interactive gaming-style courses increased by 914.6%, from 98 to 992, and virtual instructor-led training increased by 218.9%, from 2,096 to 8,151. CONCLUSIONS:In the post-pandemic period, NREMT's decision to permanently remove ADL restrictions, coupled with pandemic-related operational changes, was associated with significant, persistent shifts in CAPCE-accredited EMS CE format completions. This has resulted in sustained increases in completions of CAPCE-accredited online learning formats, including ADL, interactive gaming-style courses, and virtual instructor-led training, that persist well beyond the effects of the initial pandemic.
OBJECTIVES:Emergency medical services (EMS) clinicians primarily rely on standing protocols for prehospital care but may seek real-time physician guidance through online medical direction (OLMD) when situations fall outside established protocols. This study aimed to characterize patterns of OLMD consultation, including indications, timing, and physician decision-making within an urban EMS system and identify potential opportunities for protocol refinement. METHODS:We used an observational study design and retrospective descriptive analysis of 9,944 OLMD consultation records from July 2016 to December 2024. Data included patient demographics, consultation timing, reasons for contact, physician type, refusal factors, specific requests, hospital destinations, and the training level of the EMS clinician initiating the consultation. Records were captured in real time using Research Electronic Data Capture (REDCap) software by physicians at the University Medical Center of El Paso. Descriptive statistics were used to summarize OLMD utilization and consultation characteristics. RESULTS:In line with required clinical protocols, the common OLMD consultations included refusals, termination of resuscitation, and transport decisions. Patient refusals accounted for 65% (n = 5,175) of OLMD consultations, with physician approval documented in 97% of these cases. Requests for termination of resuscitation and transport destination changes demonstrated approval rates of 98% and 90%, respectively. Most consultations involved adult patients with a balanced sex distribution. Call volume was highest during late morning hours. Approval rates were similar between attending physicians and resident physicians (approximately 93%). CONCLUSIONS:Within this urban border EMS system, OLMD consultations are most frequently requested for patient refusals and are associated with high levels of physician agreement. These findings suggest strong alignment between paramedic clinical judgment and physician decision-making and may support expansion of standing protocols for selected clinical scenarios. Continued physician involvement remains important for complex clinical and ethical situations.
OBJECTIVES:Prehospital blood transfusion (PHBT) improves outcomes among patients with traumatic hemorrhagic shock, yet the epidemiology and geographic distribution of patients likely to require PHBT remain poorly characterized. We sought to develop predictive models for PHBT among motor vehicle crash (MVC) patients using National Emergency Medical Services Information System (NEMSIS) data and to estimate the national distribution of patients with a high predicted probability of receiving PHBT. METHODS:We conducted a retrospective cohort study using the 2024 and 2025 NEMSIS data. Eligible encounters included 9-1-1 EMS responses for MVCs among patients aged 8-100 years. A derivation cohort was constructed from EMS agencies with active PHBT programs and at least 10 documented transfusions. Candidate predictors included demographic, physiologic, clinical, and operational variables. Random forest and ridge-penalized logistic regression models were developed to identify covariates associated with PHBT. Variables selected through machine learning approaches were subsequently evaluated in multivariable logistic regression models. Model performance was assessed using area under the receiver operating characteristic curve (AUC), sensitivity, specificity, and calibration metrics. Final models were applied to the remaining national cohort to estimate patients with a high predicted probability of PHBT. RESULTS:Among 2,078,452 eligible EMS activations, 303,383 comprised the derivation cohort. The random forest-selected logistic regression model demonstrated strong discrimination with an AUC of 0.901, sensitivity of 75.3%, and specificity of 96.5%. The ridge-selected logistic regression model achieved an AUC of 0.942, sensitivity of 63.9%, and specificity of 97.7%. Both models identified composite physiologic measures, critical hemorrhagic shock designation, and unspecified traumatic shock as significant predictors of PHBT. Application of the final models to the national cohort identified 73,754 and 70,599 predicted PHBT recipients, representing 3.6% and 3.4% of the evaluated population, respectively. CONCLUSIONS:Predictive modeling applied to NEMSIS data accurately identified patients with a high probability of receiving PHBT following MVC trauma. These findings provide a framework for estimating geographic demand for prehospital blood products and may inform data-driven expansion of PHBT programs.
OBJECTIVES:Neuromuscular blockade-assisted airway management is associated with harmful physiologic adverse events, such as hypoxemia, hypotension, bradycardia, and cardiac arrest. The national scope of these events in the prehospital setting is unknown. We sought to estimate the prevalence of adverse events associated with prehospital neuromuscular blockade-assisted airway management in the United States. METHODS:We conducted an observational, cross-sectional study of the 2023 National Emergency Medical Services Information System Public-Release Research Dataset. We included all adult 9-1-1 non-cardiac arrest emergency medical services activations in which neuromuscular blockade-assisted airway management was performed. The primary outcome was the prevalence of hypoxemia, hypotension, and bradycardia within 10 min of neuromuscular blocking agent administration. The secondary outcomes were the timing of adverse events relative to neuromuscular blockade, the odds of adverse events occurring based on vital signs before neuromuscular blockade, and the prevalence of EMS-witnessed cardiac arrest after NMBA administration. RESULTS:Of 54,190,579 9-1-1 emergency medical services activations, there were 11,525 (0.02%) neuromuscular blockade-assisted airway cases. Endotracheal intubation was the first technique performed in 97.5% of cases. First pass success was 80.6%. Overall, 27.5% of patients experienced at least one adverse event in the first 10 min after neuromuscular blockade. The prevalence of hypoxemia, hypotension, bradycardia, and cardiac arrest within 10 min of neuromuscular blockade were 25.0%, 15.0%, 2.7%, and 1.9%, respectively. The odds of an adverse event occurring were higher when vital signs were abnormal before neuromuscular blockade. The presence of preexisting hypoxemia increased the odds of post-neuromuscular blockade hypoxemia by 9.1 (95% CI, 7.9-10.4) and the presence of preexisting hypotension increased the odds of post-neuromuscular blockade hypotension by 16.8 (95% CI, 13.1-21.8). Half of the cases of hypoxemia and hypotension occurred within 6 min (95% CI, 6-7) and 10 min (95% CI, 9-11), respectively. CONCLUSIONS:In this national series, 1 of every 4 patients undergoing neuromuscular blockade-assisted airway management experienced a physiologic adverse event. Emergency medical services agencies that adopt this procedure should implement measures to mitigate adverse events.
OBJECTIVES:Signs of life are observed during out-of-hospital cardiac arrest (OHCA) resuscitation, but their frequency, timing relative to return of spontaneous circulation (ROSC), and prognostic significance remain incompletely described. We evaluated the prevalence of signs of life during resuscitation and their association with survival. METHODS:We performed a retrospective observational cohort study of all OHCAs treated by a single urban emergency medical services system from January 1 through December 31, 2022. Data were abstracted from prospectively maintained OHCA and airway management registries. Signs of life include respiratory effort, eye opening or tracking, body movement, and verbal response. Each sign was classified as occurring before or after initial ROSC. We used descriptive statistics, binomial confidence intervals, and unadjusted and adjusted logistic regression to evaluate associations between signs of life, OHCA etiology, and survival. RESULTS:Among 617 treated OHCAs, 156 patients (25.3%) had at least one sign of life. Respiratory effort was most common (148 patients, 24.0%), followed by any body movement (69, 11.2%), eye opening (55, 8.9%), and any verbal response (43, 7.0%). Most documented signs occurred after ROSC, although 44 patients (7.1%) had at least one pre-ROSC sign of life. Patients with signs of life were more likely to have witnessed arrest and initial shockable rhythm and were less likely to receive intra-arrest epinephrine or prehospital advanced airway management. Survival occurred in 91 of 156 patients (58.3%) with signs of life compared with 25 of 461 patients (5.4%) without signs of life. In adjusted analysis, any sign of life was associated with survival (adjusted odds ratio [aOR] 10.3, 95% confidence interval [CI] 5.4-19.9); this relationship held when restricted to signs of life after ROSC (aOR 6.7, 95% CI 3.4-13.3). Among overdose-related OHCA, any body movement (aOR 2.44, 95% CI 1.05-5.67) and any verbal response (aOR 8.06, 95% CI 2.71-24.01) were more frequent than in the non-overdose OHCA cohort. CONCLUSIONS:One in four treated OHCA patients displayed at least one sign of life during resuscitation. Signs of life, particularly those after ROSC, were strongly associated with survival and may provide clinically useful information during prehospital resuscitation.
OBJECTIVES:Although prehospital physician involvement may affect outcomes after out-of-hospital cardiac arrest (OHCA), its effect could vary across patient subgroups. We aimed to evaluate whether physician presence is associated with improved survival in subgroups of patients with OHCA. METHODS:We used an observational study design and a retrospective secondary analysis of data from the nationwide Japanese Association for Acute Medicine OHCA registry (2014-2022). Adult patients (age ≥18 years) resuscitated after hospital arrival with complete prehospital physician data were included. The primary outcome was favorable neurological status at 30 days, defined as a cerebral performance category score of 1 or 2. Multivariate logistic regression was performed to assess the association between physician presence and outcomes, adjusting for clinically relevant confounders. Prespecified subgroup analyses were also performed according to age, witness status, bystander intervention, etiology, and extracorporeal cardiopulmonary resuscitation (ECPR) use. RESULTS:Among 83,239 patients, 9,562 had physician attendance. Physician presence was associated with favorable neurological outcomes at 30 days (adjusted odds ratio 1.49, 95% confidence interval 1.34-1.65). The association was consistent across most prespecified subgroups and was stronger among patients with unwitnessed arrest; however, no significant association was observed in patients who underwent ECPR. CONCLUSIONS:Prehospital physician presence was associated with improved neurological and survival outcomes after OHCA, with variation across patient subgroups; however, given the observational design and potential selection bias, these findings should be regarded as hypothesis-generating. Further prospective studies are warranted to define patient subgroups that benefit most from physician presence on scene and to optimize dispatch protocols accordingly.
OBJECTIVES:Extracorporeal cardiopulmonary resuscitation (ECPR) has been associated with improved survival among out-of-hospital cardiac arrest (OHCA) patients with refractory ventricular tachycardia (VT) or ventricular fibrillation (VF). However, the ideal approach for integrating an ECPR program within an emergency medical services (EMS) agency and local hospitals is unknown. The objective of this study was to investigate an EMS physician-led prehospital ECPR program. METHODS:We conducted an observational cohort study of a locally developed, EMS physician-led prehospital ECPR activation protocol within a third-service EMS agency serving an urban population and a large, academic tertiary care center in North Carolina between May 1, 2024 and May 19, 2025. Adult OHCA patients aged 18 to 60 years with non-traumatic, witnessed cardiac arrest, receipt of bystander cardiopulmonary resuscitation, and an initial rhythm of VT or VF or automated external defibrillator advised shock, refractory to three defibrillation attempts were eligible for ECPR activation. For eligible patients, paramedics consulted an online EMS physician, who could activate ECPR with subsequent intra-arrest transport to the hospital for cannulation. The primary outcome was the proportion of patients with non-traumatic OHCA who were eligible for ECPR. Secondary outcomes included the proportion of eligible patients with ECPR activation, cannulation, survival to hospital discharge, and cerebral performance category (CPC). Data were abstracted from the EMS and hospital electronic medical records. RESULTS:During the one-year study period, 347 patients experienced non-traumatic OHCA, of whom 4.3% (15/347) were eligible for ECPR. These 15 patients had a median age of 53 years (interquartile range 45-60), 80% (12/15) were male, and 60% (9/15) were non-White. The ECPR protocol was activated in 66.7% (10/15). Among these, cannulation occurred in 50% (5/10). Survival to hospital discharge occurred in 40% (4/10) of the ECPR activation group, all with CPC of 1. Among those eligible patients without ECPR activation, 60% (3/5) survived to discharge with 1 having a CPC of 1. CONCLUSIONS:The EMS physician-led ECPR protocol identified a subset of eligible patients for ECPR activation and resulted in successful cannulation of 5 patients. Further investigation in a larger, multi-system study is needed to determine the impact on patient-centered outcomes.
OBJECTIVES:The objective of this study was to characterize national patterns of pediatric emergency department (ED) utilization from 2016 through 2022, with emphasis on emergency medical services (EMS) arrival, metropolitan status, and temporal changes in diagnostic composition. METHODS:This study used a cross-sectional analysis of the National Hospital Ambulatory Medical Care Survey (NHAMCS), a nationally representative survey of United States ED visits. Survey weights were applied to generate national estimates. Emergency departments of nonfederal, general, and short-stay hospitals in the United States participating in NHAMCS. Pediatric visits (<18 years) from 2016 through 2022 were included. Main outcomes and measures included mode of arrival (EMS vs. non-EMS), triage acuity, abnormal vital signs, ED disposition, metropolitan status, and discharge diagnoses categorized using pediatric-specific International Classification of Diseases, 10th Revision (ICD-10) groupings. RESULTS:From 2016 through 2022, an estimated 202.5 million pediatric ED visits occurred, representing approximately 22% of all ED encounters. Of these, 9.0 million visits (4.4%) arrived by EMS after exclusion of interfacility transfers. Children comprised approximately 7% of EMS transports nationally. Compared with non-EMS arrivals, EMS-arriving children were more likely to be triaged as high acuity (29.8% vs 8.5%), to require hospital admission or transfer (24.9% vs. 5.3%), and to have at least one abnormal vital sign (40.4% vs. 22.6%). Injury and respiratory diseases were amongst the most common diagnostic categories for ED encounters overall. Psychiatric, behavioral, and substance use-related conditions accounted for approximately 12% of pediatric EMS encounters and increased over the study period. Although rural EDs cared for fewer pediatric visits overall, rates of abnormal vital signs were similar between urban and rural settings. Pediatric ED volume declined in 2020 and subsequently rebounded. CONCLUSIONS:Children accounted for approximately one-fifth of ED visits but only about 1 in 14 EMS transports. Pediatric EMS encounters were disproportionately high acuity and included an increasing proportion of psychiatric and behavioral conditions. Rural EDs encountered similar physiologic severity despite lower pediatric volume. These patterns underscore the low-frequency but high-severity nature of pediatric EMS encounters and highlight considerations for pediatric readiness across both prehospital and hospital emergency care systems.
OBJECTIVES:High-impact primary research is a cornerstone of emergency medical services (EMS) education and protocol development, yet EMS practitioners and EMS leaders often lack a clear, prioritized way to identify the most important recent primary literature. Because formal evidence-based guideline (EBG) development frequently lags behind emerging evidence, curated primary research plays a critical role in translating science into practice. Therefore, we sought to identify and evaluate recent high-impact EMS research-related publications through recommendations and ratings from key stakeholders and experts in EMS to identify a priority research reading list in EMS medicine. METHODS:We issued an open call through member organizations of the Prehospital Guidelines Consortium for high-impact primary literature (excluding EBGs) published between 2021-2023 related to EMS clinical care and operations. An expert panel, selected from the Prehospital Guidelines Consortium and member organizations, reviewed submissions, rating each by importance (1-5, with 5 being most important) in an asynchronous electronic survey. The expert panel selected a cut-off point using average importance rating to generate the final priority reading list. RESULTS:A total of 29 submissions resulted from the public call. After submissions outside the date range, duplicate submissions, and prehospital EBGs were excluded, nine experts in EMS medicine rated 22 submissions. The average importance rating of submissions ranged from 1.56 to 4.56. There was a natural inflection point in average importance scores at 3.56, and we classified the 10 primary articles at or above this threshold as being highly rated. CONCLUSIONS:We identified 10 high-impact primary publications to prioritize for inclusion in initial and ongoing EMS education to inform evidenced-based out-of-hospital care and address gaps in existing prehospital EBGs.
We read with significant concern the review by Millin et al. examining spinal motion restriction (SMR) for the prehospital management of patients with suspected spinal cord injury. This letter addresses the concerns of the American College of Surgeons Committee on Trauma.
OBJECTIVES:Termination-of-resuscitation (TOR) rules were derived mainly from cardiac-origin out-of-hospital cardiac arrest (OHCA), but their interpretation in foreign body airway obstruction (FBAO)-related OHCA remains uncertain. This condition is a potentially reversible hypoxic arrest in which standard TOR criteria may perform differently. We evaluated the 2025 American Heart Association basic life support (BLS)-TOR and advanced life support (ALS)-TOR criteria in FBAO-related OHCA. METHODS:This secondary analysis of the prospective Multi-center Observational CHoking Investigation (MOCHI) registry included patients with FBAO-related OHCA transported to 25 Japanese hospitals from April 2020 to March 2023. For the primary TOR analysis, we included patients who had not achieved return of spontaneous circulation (ROSC) before emergency medical services (EMS) arrival, because TOR rules are intended for patients who remain in cardiac arrest at the time of EMS assessment. Patients were retrospectively classified according to BLS-TOR and ALS-TOR criteria. Primary measures were the specificity of TOR-positive status for predicting unfavorable neurological outcome, defined as the proportion of patients with favorable neurological outcome (Cerebral Performance Category 1-2) who were classified as TOR-negative, and the proportion of TOR-positive patients who nevertheless achieved favorable neurological outcome. RESULTS:Of 248 patients with FBAO-related OHCA (median age, 81.5 years; 83.1% witnessed), 49 (19.8%) survived to 30 days and 9 (3.6%) achieved favorable neurological outcome. The BLS-TOR rule classified 150/229 evaluable patients as TOR-positive; 2 achieved favorable neurological outcome (1.3%; 95% CI, 0.4-4.7; specificity, 77.8% [95% CI, 45.3-93.7]), and 20 survived to 30 days (13.3%; 95% CI, 8.8-19.7). The ALS-TOR rule classified 12/242 patients as TOR-positive; none achieved favorable neurological outcome, but 4 survived to 30 days (33.3%; 95% CI, 13.8-60.9). CONCLUSIONS:In FBAO-related OHCA, BLS-TOR would have classified two patients with favorable neurological outcome as TOR-positive. The ALS-TOR rule was restrictive, but small numbers and 30-day survival among TOR-positive patients preclude firm safety conclusions. Termination-of-resuscitation criteria warrant cautious, etiology-aware interpretation when FBAO is suspected.
OBJECTIVES:Prehospital transfusion using Rh-D antigen positive low-titer group O whole blood (LTOWB) or red blood cells is increasingly common when RhD-negative blood products are not available. However, concerns remain regarding D-alloimmunization in RhD-negative females of childbearing potential (FCPs), which could lead to future hemolytic disease of the fetus and newborn (HDFN). The magnitude of these risks, and their policy implications, have been the subject of recent investigation. The objectives of this review are to summarize the biological and epidemiological impacts and post-exposure management of RhD-positive transfusion in FCPs in hemorrhagic shock. METHODS:This narrative review synthesizes the literature on the rate of D-alloimmunization, describes the results of modeling studies on the risk of HDFN following RhD-positive transfusion to FCPs, and examines epidemiologic studies estimating the HDFN risk at local, regional, and national levels. The D-alloimmunization risk mitigation strategies and current clinical guidelines are also reviewed. RESULTS:Several factors, including the low prevalence of RhD-negative individuals, the low rate of D-alloimmunization itself, potentially reduced pregnancy rates post-trauma, and advances in modern perinatal care decrease the overall risk of HDFN following the transfusion of RhD-positive blood products to FCPs in trauma. Some modeling studies estimated that fetal death due to anti-D-mediated HDFN would occur in fewer than 0.1% of FCPs exposed to RhD-positive blood products. Timely prehospital transfusion has demonstrated survival benefits for injured adults and children. National and regional epidemiological studies support the safety and utility of RhD-positive blood product use in emergency settings. Risk mitigation strategies include Rh immune globulin (RhIg) administration and structured post-exposure follow-up to detect alloimmunization and reduce potential future pregnancy harm. CONCLUSIONS:RhD-positive transfusion in FCPs during hemorrhagic shock when RhD-negative products are not available is supported by current evidence and ethical considerations. The risk of future HDFN is low and favorable perinatal outcomes can be achieved when the woman has access to modern prenatal health care. Risk may be further mitigated through post-exposure protocols. Prehospital transfusion policies should reflect this risk-benefit balance by enabling access to RhD-positive blood products for all trauma patients, including FCPs, if RhD-negative blood products are not available.
OBJECTIVES:Trauma is a leading cause of death among children in the United States. Prehospital blood product administration is a potentially lifesaving measure for injured children. We evaluated how often injured children meet physiological criteria for transfusion, determined the use of prehospital blood products in this sample, and identified agency characteristics that can inform the implementation of additional prehospital transfusion programs. METHODS:We conducted a retrospective analysis of the 2021-2024 National Emergency Medical Services Information System (NEMSIS) datasets. We included children (<18 years) with injury. We identified patients who may be eligible for prehospital blood transfusion based on (a) a combination of a systolic blood pressure (SBP) below the 5th centile for age and elevated heart rate above the 85th centile or (b) a systolic blood pressure below the 1st centile. We characterized encounters potentially eligible for prehospital blood transfusion, the use of blood products in this group, and the EMS agencies that cared for these patients. RESULTS:Of 2,492,731 encounters, 34,221 (1.37%, 95% confidence interval [CI] 1.36%, 1.39%) were potentially eligible for blood transfusion. Patients meeting these criteria were more frequently adolescents (71.1%) and were involved in falls (23.4%) or motor vehicle collisions (22.6%). Blood products were administered in 669 (0.027%; 95% CI 0.025%, 0.029%) encounters overall and to 1.01% (95% CI 0.91%, 1.13%) of encounters meeting criteria for blood transfusion eligibility. In agency-level analysis, 240/16,848 (1.4%) agencies provided blood products to children, and 84.4% of eligible patients were cared for by agencies whose most common level of service was advanced life support (ALS). In multivariable analysis, agencies caring for pediatric trauma patients meeting physiologic criteria for transfusion were more likely to have higher levels of service (ALS or critical care); rural; mixed volunteer/non-volunteer; and governmental non-fire, hospital, or private, non-hospital (vs fire departments). CONCLUSIONS:In a nationally representative prehospital sample, many injured children appeared eligible for transfusion. Prehospital blood product use was uncommon and varied by system factors. Expanding access will require implementation of blood programs among EMS agencies most likely to treat these patients, and consideration for equipment and protocols that allow for administration of blood to children.
