OBJECTIVES:The Screening, Brief Intervention, and Referral to Treatment (SBIRT) framework is a validated process that is used to identify individuals with substance use disorders (SUDs) and then encourage them to engage in and facilitate entry into treatment. It is not known how well SBIRT can be incorporated into prehospital practice and what barriers to Emergency Medical Services (EMS) implementation of an SBIRT program might arise. The aim of this project was to implement a pilot EMS based SBIRT program. Then, after program implementation, to identify barriers to the prehospital use of SBIRT programs. METHODS:This was a mixed methodology study utilizing a retrospective review of program quality improvement data and structured interviews to collect both objective and subjective data on the prehospital SBIRT implementation. Eight EMS agencies participated in the SBIRT pilot program. Paramedics and Emergency Medical Technicians (EMT) were trained to use the SBIRT process then asked to use the SBIRT tool during their day to day activities. The screening tools utilized were the Drug Abuse Screening Test (DAST) and the Alcohol Use Disorders Identification Test (AUDIT). Referral tools were tailored to the unique SUD treatment programs available in each community. The pilot program was run for 6 months after which time structured focus group meetings were conducted to identify barriers to broader SBIRT program utilization. RESULTS:In total, 28 EMS clinicians from 8 agencies attended the train the trainer SBIRT education session. None of the agencies subsequently implemented the routine use of the SBIRT model or DAST/AUDIT tools. The agencies reported significant barriers to implementation on EMS calls, including short transport times, current drug and/or alcohol intoxication, and hesitation of patients to participate. Community paramedicine clinicians, who typically spend more time with patients, found the tools more useful but found limited opportunities to implement them. Common cited themes were the lack of local community-based organizations and frequent personnel turnover within local agencies. CONCLUSIONS:Although EMS clinicians found the SBIRT training to be useful, they did not incorporate the use of the SBIRT model into their prehospital patient care, citing too many barriers to its implementation and use.

Background: It is well established that prehospital hypoxia dramatically increases mortality in Traumatic Brain Injury (TBI). Thus, in EMS TBI research, case ascertainment and risk adjustment are highly dependent upon documentation of in-field O 2 saturation (SpO 2 ). Objective: To compare the rate of hypoxia identified by EMS personnel and documented in EMS patient care records (PCR) versus the actual rate of hypoxia recorded by continuous, non-invasive monitoring in TBI. Methods: A subset of major TBI cases (moderate/severe) from 5 EMS agencies reporting monitor data (Philips MRx™) in the EPIC EMS TBI Study (NIH 1R01NS071049) were evaluated (02/13-02/18). All monitor data available for post-hoc review were displayed and accessible to the providers during EMS care. We compared PCR documentation of hypoxia (SpO 2 <90%) to continuous monitor data in TBI patients (nasal canula O 2 , mask, basic or advanced airway). Statistic: exact McNemar’s test, α=0.05. Results: 120 cases were included [med. age 50; IQR (23.8, 68); 65% male. Monitors recorded 44 hypoxic cases (36.7%; 95%CI 28.1, 45.9%). Only 8 (6.7%; 2.9, 12.7%) were documented in the PCR (p<0.0001; Figure). Three machine-detected hypoxia cases had no PCR-documented SpO 2 at all. Conclusions: The difference in PCR-documented and monitor-identified hypoxia was dramatic. The monitor data revealed a five-fold greater incidence of hypoxia than that documented by EMS providers. This may be partially explained by the continuous nature of pulse oximetry in the face of ongoing care responsibilities and scene distractions. The field environment may cause providers to miss low readings as they fluctuate moment-by-moment. These findings have major clinical implications. While some of the discrepancy between PCR reporting and monitor data might simply be failure to document hypoxia, the much more concerning implication is that many cases might be unrecognized and untreated. Furthermore, these findings have important implications for case ascertainment, confounding, and risk-adjustment in EMS TBI research. Whenever possible, quality improvement and research projects should utilize continuous non-invasive monitor data to identify and evaluate hypoxic patients in the setting of TBI. These findings may also have implications for identifying hypoxia in EMS patients with other critical conditions.

Background:Telemedicine remains an underused tool in rural emergency medical servces (EMS) systems. Rural emergency medical technicians (EMT) and paramedics cite concerns that telemedicine could increase Advanced Life Support (ALS) transports, extend on-scene times, and face challenges related to connectivity as barriers to implementation. Our aim in this project was to implement a telemedicine system in a rural EMS setting and assess the impact of telemedicine on EMS management of patients with chest pain while evaluating some of the perceived barriers. Methods:This study was a mixed-methods, retrospective review of quality assurance data collected prior to and after implementation of a telemedicine program targeting patients with chest pain. We compared quantitative data from the 12-month pre-implementation phase to data from 15 months post-implementation. Patients were included if they had a chief complaint of chest pain or a 12-lead electrocardiogram had been obtained. The primary outcome was the rate of ALS transport before and after program implementation. Secondary outcomes included EMS call response times and EMS agency performance on quality improvement benchmarks. Qualitative data were also collected after each telemedicine encounter to evaluate paramedic/EMT and EMS physician perception of call quality. Results:The telemedicine pilot project was implemented in September 2020. Overall, there were 58 successful encounters. For this analysis, we included 38 patients in both the pre-implementation period (September 9, 2019-September 10, 2020) and the post-implementation period (September 11, 2020-December 5, 2021). Among this population, the ALS transport rate was 42% before and 45% after implementation (odds ratio 1.11; 95% confidence interval 0.45-2.76). The EMS median out-of-service times were 47 minutes before, and 33 minutes after (P = 0.07). Overall, 64% of paramedics/EMTs and 89% of EMS physicians rated the telemedicine call quality as "good." Conclusion:In this rural EMS system, a telehealth platform was successfully used to connect paramedics/EMTs to board-certified EMS physicians over a 15-month period. Telemedicine use did not alter rates of ALS transports and did not increase on-scene time. The majority of paramedics/EMTs and EMS physicians rated the quality of the telemedicine connection as "good."

AbstractObjectivesTraumatic brain injury (TBI) is an important public health problem resulting in significant death and disability. Emergency medical services (EMS) personnel often provide initial treatment for TBI, but only limited data describe the long‐term course and outcomes of this care. We sought to characterize changes in neurologic status among adults with TBI patients enrolled in the Resuscitation Outcomes Consortium Hypertonic Saline (ROC‐HS) trial.MethodsWe used data from the TBI cohort of the ROC‐HS trial. The trial included adults with TBI, with Glasgow Coma Scale (GCS) ≤8, and excluded those with shock (systolic blood pressure [SBP] ≤70 or SBP 71–90 with a heart rate [HR] ≥108). The primary outcome was Glasgow Outcome Scale–Extended (GOS‐E; 1 = dead, 8 = no disability) determined at (a) hospital discharge and (b) 6‐month follow‐up. We assessed changes in GOS‐E between hospital discharge and 6‐month follow‐up using descriptive statistics and Sankey graphs.ResultsAmong 1279 TBI included in the analysis, GOS‐E categories at hospital discharge were as follows: favorable (GOS‐E 5–8) 220 (17.2%), unfavorable (GOS‐E 2–4) 664 (51.9%), dead (GOS‐E 1) 321 (25.1%), and missing 74 (5.8%). GOS‐E categories at 6‐month follow‐up were as follows: favorable 459 (35.9%), unfavorable 279 (21.8%), dead 346 (27.1%), and missing 195 (15.2%). Among initial TBI survivors with complete GOS‐E, >96% followed one of three neurologic recovery patterns: (1) favorable to favorable (20.0%), (2) unfavorable to favorable (40.3%), and (3) unfavorable to unfavorable (36.0%). Few patients deteriorated from favorable to unfavorable neurologic status, and there were few additional deaths.ConclusionsAmong TBI receiving initial prehospital care in the ROC‐HS trial, changes in 6‐month neurologic status followed distinct patterns. Among TBI with unfavorable neurologic status at hospital discharge, almost half improved to favorable neurologic status at 6 months. Among those with favorable neurologic status at discharge, very few worsened or died at 6 months. These findings have important implications for TBI clinical care, research, and trial design.

Importance The Excellence in Prehospital Injury Care (EPIC) study demonstrated improved survival in patients with severe traumatic brain injury (TBI) following implementation of the prehospital treatment guidelines. The impact of implementing these guidelines in the subgroup of patients who received positive pressure ventilation (PPV) is unknown. Objective To evaluate the association of implementation of prehospital TBI evidence-based guidelines with survival among patients with prehospital PPV. Design, Setting, and Participants The EPIC study was a multisystem, intention-to-treat study using a before/after controlled design. Evidence-based guidelines were implemented by emergency medical service agencies across Arizona. This subanalysis was planned a priori and included participants who received prehospital PPV. Outcomes were compared between the preimplementation and postimplementation cohorts using logistic regression, stratified by predetermined TBI severity categories (moderate, severe, or critical). Data were collected from January 2007 to June 2017, and data were analyzed from January to February 2023. Exposure Implementation of the evidence-based guidelines for the prehospital care of patient with TBI. Main Outcomes and Measures The primary outcome was survival to hospital discharge, and the secondary outcome was survival to admission. Results Among the 21 852 participants in the main study, 5022 received prehospital PPV (preimplementation, 3531 participants; postimplementation, 1491 participants). Of 5022 included participants, 3720 (74.1%) were male, and the median (IQR) age was 36 (22-54) years. Across all severities combined, survival to admission improved (adjusted odds ratio [aOR], 1.59; 95% CI, 1.28-1.97), while survival to discharge did not (aOR, 0.94; 95% CI, 0.78-1.13). Within the cohort with severe TBI but not in the moderate or critical subgroups, survival to hospital admission increased (aOR, 6.44; 95% CI, 2.39-22.00), as did survival to discharge (aOR, 3.52; 95% CI, 1.96-6.34). Conclusions and Relevance Among patients with severe TBI who received active airway interventions in the field, guideline implementation was independently associated with improved survival to hospital admission and discharge. This was true whether they received basic airway interventions or advanced airways. These findings support the current guideline recommendations for aggressive prevention/correction of hypoxia and hyperventilation in patients with severe TBI, regardless of which airway type is used.

Background: The EMS traumatic brain injury (TBI) guidelines recommend limiting intubation (ETI) to patients with profoundly-depressed level of consciousness (LOC) and who cannot protect their airway or adequately ventilate with basic maneuvers. Thus, many major TBIs are managed without ETI in the field. Monitoring ETCO2 via nasal sensors (NC-CO2) in non-ETI patients may provide valuable information about ventilatory status and trends. However, EMS NC-CO2 remains unstudied. Objective: To evaluate the association between LOC and NC-CO2 in non-intubated TBI. Methods: Cases from 7 EMS agencies reporting continuous monitor data (Philips MRx™) in the EPIC TBI Study (NIH 1R01NS071049) were evaluated (4/13-4/18). Comparisons in patient-level mean, median, lowest and highest NC-CO2 levels were made across GCS categories using clinically meaningful thresholds: <15, <12, <9, 3. Results: Included: 177 cases [median age: 52 (range: 9-94), 66% male]. Overall, while not statistically significant, NC-CO2 tended to be lower in patients with lower GCS (Table). In addition, minimum NC-CO2 was significantly lower (p=0.01) in patients with compromised LOC (Table). O2 management (Hi-flow/Lo-flow/No O2) was documented in 176 patients (99.4%). Among the 107 patients with all GCS = 15, 44 (41%) had Hi-flow administered compared to 47/69 (68%) with any GCS <15 (p=0.0008). Conclusion: The utility of prehospital capnography in non-intubated patients is unknown. In this study, NC-CO2 tended to be lower in TBI patients with lower GCS. Whether this reflects physiological/respiratory differences with changes in LOC, or variations in methods of managing oxygenation is unclear. These intriguing new findings require future study to determine if NC-CO2 is directly reflective of LOC-related ventilatory patterns. Furthermore, studies are needed to evaluate whether NC-CO2 monitoring has clinical utility as a non-invasive adjunct to care in spontaneously-breathing, non-ETI patients.

Introduction Medication automatic dispensing systems (ADS) have been implemented in many settings, including fire-based EMS stations. The aim of this study was to evaluate the impact of in-station ADSs on controlled substance administration rates and EMS response intervals. Methods This study was a retrospective review of data from a single fire-based EMS agency. Medication administration rates and EMS response intervals were compared before ADS implementation (P1; 6/1/15 to 5/31/16) and after ADS implementation (P3; 6/1/17-5/31/19). Cases with missing data and during a one-year implementation period were excluded. Results 4045 cases were identified in P1 and 8168 in P3. The odds of morphine or versed administration increased following ADS implementation: OR = 1.77 (95% CI: 1.53, 2.03) and OR = 1.53 (95%CI: 1.18, 2.00) respectively. There were statistically, but likely not operationally significant increases in median response interval and transport interval from P1 to P3 of 14 seconds, (p < 0.001) and 39 seconds (p < 0.001) respectively. Time at hospital for all calls decreased by more than 11 minutes for all transports, from a median of 34 minutes (IQR; 23.7, 45.5) to 22.7 minutes (IQR:18.5, 27.6) in P3, p < 0.001 and by 27.9 minutes for calls in which a controlled substance was given: P1 = 50.6 minutes (IQR: 34.6, 63.2), P3 = 22.7 minutes (IQR: 18.3, 27.4), p < 0.001. Conclusion In this system, medication ADS implementation was associated with an increase in the rates of controlled substance administration and a decrease in the time units were at hospitals.

ABSTRACTBACKGROUNDLittle is known about the trajectory over time of neurologic recovery after traumatic brain injury (TBI). We sought to determine long-term changes in neurologic status after prehospital clinical trial interventions for acute TBI.METHODSWe used data from the Resuscitation Outcomes Consortium Hypertonic Saline (ROC HS) TBI Trial. The trial included adult TBI, with Glasgow Coma Scale (GCS)≤8 and excluded those with shock (systolic blood pressure (SBP)≤70, or SBP 71-90 with HR≥108). The primary outcome was Glasgow Outcome Scale-Extended (GOS-E; 1=dead, 8=no disability) determined at: a) hospital discharge and b) 6-month follow-up. We analyzed changes in GOS-E between hospital discharge and 6-month follow-up by examining median changes with exact 95% confidence intervals (CI), mean changes with bootstrapped 95% CIs and Sankey graphs. We repeated the analysis for the high acuity subset of patients undergoing prehospital advanced airway insertion.RESULTSAmong 1,279 TBI subjects included in the analysis, GOS-E categories at hospital discharge were: favorable (GOS-E 5-8) 220 (17.2%), unfavorable (GOS-E 2-4) 664 (51.9%), dead (GOS-E 1) 321 (25.1%), missing 74 (5.8%). GOS-E categories at 6-month follow-up were: favorable 459 (35.9%), unfavorable 279 (21.8%), dead 346 (27.1%), missing 195 (15.2%). Among initial TBI survivors with complete GOS-E, >96% followed one of three neurologic recovery trajectories: 1) favorable to favorable (20.0%), 2) unfavorable to favorable (40.3%), and 3) unfavorable to unfavorable (36.0%). Few patients deteriorated from favorable to unfavorable neurologic status and there were few additional deaths.CONCLUSIONNeurologic recovery after TBI follows distinct trajectories. Among those with TBI and unfavorable neurologic status at hospital discharge, almost half will improve to favorable neurologic status at six months. Among those with favorable neurologic status at discharge, very few worsen to unfavorable neurologic status or death at six months. These findings have important implications for TBI clinical care, research and trial design.

Implementation of the Guidelines - How do we put the new ERC Guidelines into practice? On 16 and 17 June, we are organising our first-ever hybrid congress. You will be able to join us live at the beautiful conference venue in Antwerp, Belgium and present your Poster. We are happy to welcome you to Resuscitation 2022!

Context: As many as 14% of patients transported by ambulance with chest pain die prior to hospital discharge. To date, no high-quality controlled trials have revealed that prehospital advanced life support interventions affect survival for these patients. Objective: The Ontario Prehospital Advanced Life Support (OPALS) Study assessed the effect of adding an advance life support service to an existing basic life support emergency medical service program, on the rate of mortality and morbidity for patients with out-of-hospital chest pain. Design: Controlled clinical trial comparing survival for 9 months before and 9 after instituting an advanced life support program. Setting: Thirteen urban and suburban Ontario communities (populations ranging from 30,000 to 750,000; total, 2.5 million). Patients: All adult patients with a primary complaint of chest pain and transported by paramedics to the emergency department. Intervention: Paramedics were trained in standard advanced life support, which includes endotracheal intubation, intravenous furosemide and morphine, oral ASA, and sublingual NTG. Emergency medical services within each community had to meet predefined criteria in order to qualify for the advanced life support phase. Main Outcome Measure: Survival to hospital discharge. Results: Overall, 12,168 patients were enrolled in either the basic life support phase (N = 5,788) or the advanced life support phase (N = 6,380). The rate of mortality significantly decreased from 4.3% in the basic life support phase to 3.2% in the advanced life support phase (absolute change 1.1, 95% CI 0.4-1.8, P = 0.0013). We also demonstrated a decrease in mortality for the subgroup of patients with a discharge diagnosis of myocardial infarction (13.1 percent vs 8.2 percent, P = 0.002). Conclusions: The addition of a prehospital advanced life support program to an existing basic life support emergency medical service was associated with a significant decrease in the mortality rate among patients complaining of chest pain. Future research should clarify the most effective interventions and target specific populations.

Background: The advent of highly sensitive End-Tidal CO2 (ETCO2) sensors allows effective monitoring of intubated patients in EMS. Previous work has explored the use of ETCO2 monitoring in non-intubated patients with sensors placed in the nares. However, little is known about the effect of passive O2 delivery [nasal cannula (NC) or high-flow, non-rebreather mask (NRB)] on ETCO2 measurement. Objective: To compare ETCO2 measurements in non-intubated Traumatic Brain Injury (TBI) patients receiving O2 via NC vs. NRB in the field. Methods: A subset of cases from the EPIC EMS TBI Study (NIH-1R01NS071049) were evaluated (4/13-4/18). Non-intubated cases from 5 EMS agencies providing monitor data, including continuous ETCO2. Start and end segments were excluded to remove artifact from initiation (“ramp-up”) or termination of monitoring. Statistics: Wilcoxon rank-sum test, two-sample t-test, and Chi-squared test were used as appropriate. Linear regression compared continuous variables in adjusted analyses (α = 0.05). Results: Included were 151 cases [median age: 52 (range: 9-91; 66% male)]. Of those, 62 (41%) received NCO2 and 89 (59%) via NRB. Patient-level mean ETCO2 was slightly lower in the NC group (mean = 26.9 mmHg; SD 6.7) compared to NRB (mean 30.2; SD 8.1; p=0.007). Differences in the mean were: Unadjusted: 3.3 (95% CI 0.9-5.7); Adjusted 2.7 (0.2-5.2). There were no significant differences in means of the patient-level lowest or highest recorded values. Conclusion: While there was a statistically lower ETCO2 in the NC versus NRB-oxygenated patients, it was around 3 mmHg and, thus, not clinically significant. This is surprising since: 1) the O2 flow rates and 2) the open-air (NC) versus mask (NRB) delivery methods are so dramatically different. Future study is needed to identify the clinical implications of using noninvasive ETCO2 measurement as a tool for monitoring ventilatory status and changes in non-intubated TBI (and other) patients in emergency settings.

BACKGROUND AND OBJECTIVE:Hypotension has a powerful effect on patient outcome after traumatic brain injury (TBI). The relative impact of hypotension occurring in the field versus during early hospital resuscitation is unknown. We evaluated the association between hypotension and mortality and non-mortality outcomes in four cohorts defined by where the hypotension occurred [neither prehospital nor hospital, prehospital only, hospital only, both prehospital and hospital]. METHODS:Subjects ≥10 years with major TBI were included. Standard statistics were used for unadjusted analyses. We used logistic regression, controlling for significant confounders, to determine the adjusted odds (aOR) for outcomes in each of the three cohorts. RESULTS:Included were 12,582 subjects (69.8% male; median age 44 (IQR 26-61). Mortality by hypotension status: No hypotension: 9.2% (95%CI: 8.7-9.8%); EMS hypotension only: 27.8% (24.6-31.2%); hospital hypotension only: 45.6% (39.1-52.1%); combined EMS/hospital hypotension 57.6% (50.0-65.0%); (p < 0.0001). The aOR for death reflected the same progression: 1.0 (reference-no hypotension), 1.8 (1.39-2.33), 2.61 (1.73-3.94), and 4.36 (2.78-6.84), respectively. The proportion of subjects having hospital hypotension was 19.0% (16.5-21.7%) in those with EMS hypotension compared to 2.0% (1.8-2.3%) for those without (p < 0.0001). Additionally, the proportion of patients with TC hypotension was increased even with EMS "near hypotension" up to an SBP of 120 mmHg [(aOR 3.78 (2.97, 4.82)]. CONCLUSION:While patients with hypotension in the field or on arrival at the trauma center had markedly increased risk of death compared to those with no hypotension, those with prehospital hypotension that was not resolved before hospital arrival had, by far, the highest odds of death. Furthermore, TBI patients who had prehospital hypotension were five times more likely to arrive hypotensive at the trauma center than those who did not. Finally, even "near-hypotension" in the field was strongly and independently associated the risk of a hypotensive hospital arrival (<90 mmHg). These findings are supportive of the prehospital guidelines that recommend aggressive prevention and treatment of hypotension in major TBI.

Study objective Little is known about the out-of-hospital blood pressure ranges associated with optimal outcomes in traumatic brain injuries (TBI). Our objective was to evaluate the associations between out-of-hospital systolic blood pressure (SBP) and multiple hospital outcomes without assuming any predefined thresholds for hypotension, normotension, or hypertension. Methods This was a preplanned secondary analysis from the Excellence in Prehospital Injury Care (EPIC) TBI study. Among patients (age ≥10 years) with major TBIs (Barell Matrix type 1 and/or Abbreviated Injury Scale-head severity ≥3) and lowest out-of-hospital SBPs of 40 to 299 mmHg, we utilized generalized additive models to summarize the distributions of various outcomes as smoothed functions of SBP, adjusting for important and significant confounders. The subjects who were enrolled in the study phase after the out-of-hospital TBI guideline implementation were used to validate the models developed from the preimplementation cohort. Results Among 12,169 included cases, the mortality model revealed 3 distinct ranges: (1) a monotonically decreasing relationship between SBP and the adjusted probability of death from 40 to 130 mmHg, (2) lowest adjusted mortality from 130 to 180 mmHg, and (3) rapidly increasing mortality above 180 mmHg. A subanalysis of the cohorts with isolated TBIs and multisystem injuries with TBIs revealed SBP mortality patterns that were similar to each other and to that of the main analysis. While the specific SBP ranges varied somewhat for the nonmortality outcomes (hospital length of stay, ICU length of stay, discharge to skilled nursing/inpatient rehabilitation, and hospital charges), the patterns were very similar to that of mortality. In each model, validation was confirmed utilizing the postimplementation cohort. Conclusion Optimal adjusted mortality was associated with a surprisingly high SBP range (130 to 180 mmHg). Below this level, there was no point or range of inflection that would indicate a physiologically meaningful threshold for defining hypotension. Nonmortality outcomes showed very similar patterns. These findings highlight how sensitive the injured brain is to compromised perfusion at SBP levels that, heretofore, have been considered adequate or even normal. While the study design does did not allow us to conclude that the currently recommended treatment threshold (<90 mmHg) should be increased, the findings imply that the definition of hypotension in the setting of TBI is too low. Randomized trials evaluating treatment levels significantly higher than 90 mmHg are needed.

Objective : Little is known about the time-based trajectories of neurologic recovery after traumatic brain injury (TBI). We sought to determine long-term changes in neurologic status after TBI. Methods: Data source: Resuscitation Outcomes Consortium Hypertonic Saline TBI Trial. Included: adult TBI, GCS≤8; Excluded: shock (SBP≤70, or SBP 71-90 with HR≥108). Primary outcome: Glasgow Outcome Scale-Extended (GOS-E; 1=dead, 8=no disability) determined at: a) hospital discharge and b) 6-months. We analyzed changes in GOS-E between hospital discharge and 6-months using Sankey graphs and the Wilcoxon signed-rank test. We repeated the analysis for the high acuity subset of patients undergoing EMS advanced airway insertion. Results: Among 1,282 TBI, GOS-E at discharge was: dead (GOS-E 1) n=321 (25.0%), unfavorable (2-4) n=664 (51.8%), favorable (5-8) n=220 (17.2%), missing n=77 (6.0%; Figure). GOS-E at 6-months was: dead n=346 (27.0%), unfavorable n=282 (22.0%), favorable n=459 (35.8%), missing n=195 (15.2%). While 7 of 220 (3.2%) with favorable GOS-E at discharge worsened at 6 months (unfavorable or died), 300 of 664 (45.2%) with unfavorable GOS-E improved to favorable at 6 months (Wilcoxon signed-rank for GOS-E change p<0.0001). In the EMS advanced airway subset (n=774), 2 of 96 (7.1%) with favorable GOS-E at discharge worsened to unfavorable (or were dead) at 6 months, while 208 of 433 (48.0%) with unfavorable GOS-E improved to favorable at 6 months (Wilcoxon signed-rank for GOS-E change p<0.0001). Conclusion: Among patients with TBI and unfavorable neurologic status at hospital discharge, almost half will progress to favorable neurologic status at 6 months. Very few TBI victims die or worsen to unfavorable neurologic status by the time of 6-month follow-up. Thus, assessment of long-term neurologic outcome should be considered for studies of TBI.

Background: Prehospital and early hospital hypoxia powerfully affect traumatic brain injury (TBI) outcomes. However, the correlations between EMS and hospital O2 saturations are unknown. Using the EPIC Study data (NIH-1R01NS071049; DOD-W81XWH-19-C-0058), we assessed correlations between EMS SpO2 and the risk of major TBI patients arriving at the trauma center (TC) with hypoxia (initial ED SpO2<90%). Methods: Subjects meeting EPIC Study criteria, age ≥10 years, and transported directly to the TC were included. Basic statistics were determined by Kruskal-Wallis, Chi-square or Fisher’s exact test. Adjusted odds (aOR) were assessed using logistic regression, controlling for significant confounders. Results: A total of 10,370 subjects were included. Compared to no hypoxia, aORs for death were: EMS, but no TC hypoxia: 2.1 (1.7-2.6), TC, but no EMS hypoxia: 2.5 (1.7-3.8), both EMS/TC hypoxia: 3.2 (2.1-4.8; p<0.0001). Among the 9,243 cases with no EMS hypoxia, only 242 [2.6% (2.3%-3.0%) were hypoxic at TC arrival, compared to 215 of 1127 cases that had EMS hypoxia [19.1% (16.8%, 21.5%); OR: 8.8 (7.2, 10.7); aOR: 4.6 (3.7, 5.7); p<0.0001]. The Figure shows the odds of arriving hypoxic at the TC, based upon the lowest recorded EMS SpO2 (whether hypoxic or not). Conclusion: As expected, hypoxia upon TC arrival was highly correlated with EMS hypoxia (OR 8.8, aOR 4.6). However, it is remarkable that even a single EMS SpO2 below 100% was associated with 2.4 greater odds of TC hypoxia (<90%). Given our recent findings that the optimal odds of survival occurs in patients whose recorded EMS SpO2s were always 100%, these findings argue against the popular concept of preventing “ hyper -oxia” by titrating O2 to maintain SpO2 in the mid/upper 90s. Our results imply that keeping EMS SpO2 as high as possible prevents subsequent hypoxic episodes (i.e., “pre-oxygenation” for unexpected deterioration) and supports maintaining an SpO2 of 100% during the prehospital interval in major TBI.

Study objective: We evaluate the effect of implementing the out-of-hospital pediatric traumatic brain injury guidelines on outcomes in children with major traumatic brain injury. Methods: The Excellence in Prehospital Injury Care for Children study is the preplanned secondary analysis of the Excellence in Prehospital Injury Care study, a multisystem, intention-to-treat study using a before-after controlled design. This subanalysis included children younger than 18 years who were transported to Level I trauma centers by participating out-of-hospital agencies between January 1, 2007, and June 30, 2015, throughout Arizona. The primary and secondary outcomes were survival to hospital discharge or admission for children with major traumatic brain injury and in 3 subgroups, defined a priori as those with moderate, severe, and critical traumatic brain injury. Outcomes in the preimplementation and postimplementation cohorts were compared with logistic regression, adjusting for risk factors and confounders. Results: There were 2,801 subjects, 2,041 in preimplementation and 760 in postimplementation. The primary analysis (postimplementation versus preimplementation) yielded an adjusted odds ratio of 1.16 (95% confidence interval 0.70 to 1.92) for survival to hospital discharge and 2.41 (95% confidence interval 1.17 to 5.21) for survival to hospital admission. In the severe traumatic brain injury cohort (Regional Severity Score-Head 3 or 4), but not the moderate or critical subgroups, survival to discharge significantly improved after guideline implementation (adjusted odds ratio = 8.42; 95% confidence interval 1.01 to 100thorn). The improvement in survival to discharge among patients with severe traumatic brain injury who received positivepressure ventilation did not reach significance (adjusted odds ratio = 9.13; 95% confidence interval 0.79 to 100thorn). Conclusion: Implementation of the pediatric out-of-hospital traumatic brain injury guidelines was not associated with improved survival when the entire spectrum of severity was analyzed as a whole (moderate, severe, and critical). However, both adjusted survival to hospital admission and discharge improved in children with severe traumatic brain injury, indicating a potential severity-based interventional opportunity for guideline effectiveness. These findings support the widespread implementation of the out-of-hospital pediatric traumatic brain injury guidelines.

Background: Little is known about the provision of care by law enforcement (LE) personnel within modern EMS systems. We evaluated LE performance of bystander CPR (BCPR) and associated outcomes in OHCA across Arizona. Methods: A total of 5,654 OHCA cases (1/1/2019-12/31/2019) were evaluated using the Save Hearts in Arizona Registry and Education (SHARE) cardiac arrest registry. Data were abstracted from all EMS patient care records (PCRs). If two parties provided BCPR, the first to give compressions was considered the provider for this analysis. Cases identified as “Stranger” or “Unknown” BCPR were manually evaluated for narrative data to identify BCPR provider when possible. Results: BCPR was provided in 2285 cases [48.8%; (95% CIs 47.4%, 50.3%)] after excluding 850 cases that occurred in healthcare facilities where personnel are duty-bound to provide CPR. LE provided BCPR in 444 patients [19.4% (17.8%, 21.1%)], second only to family/spouse [1143 pts; 50.0% (48.0%, 52.1%)]. Overall, 279 patients survived to hospital discharge [12.2%, (10.9%, 13.6%)]. The Table shows the rates of BCPR in each provider category and the associated rates of survival. Of note is that the rate of bystander AED use was more than four times higher in LE BCPR [6.3% (4.23%, 8.99%)] than family-provided BCPR [1.5% (0.87%, 2.37%; p < 0.0001)], but was still very low. Conclusions: In this statewide study that included more than 130 EMS agencies from frontier to urban settings, LE personnel were frequently involved in the care of OHCA patients within the 911 system response. To our knowledge, this magnitude of provision of BCPR by LE (nearly one in five BCPR cases) has not been reported previously. Furthermore, the consequential rate of LE response to OHCA provides the opportunity to significantly increase AED use. Our findings support the widespread and intentional training of LE in CPR and AED use and has the potential to improve survival in diverse settings.