EMS World

OCT 2018

EMS World Magazine is the most authoritative source in the world for clinical and educational material designed to improve the delivery of prehospital emergency medical care.

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Page 69 of 87

EMSWORLD.com | OCTOBER 2018 69 OCTOBER 29 - NOVEMBER 2, 2018 NASHVILLE, TENNESSEE had 26% decreased odds of transport compared to non-His- panic white patients (aOR 0.74; 95% CI: 0.73–0.75). Compared to patients aged 18–39, older patients had progressively greater odds of transport with each age group, the largest aOR being 2.62 (95% CI, 2.59–2.65) for those older than 79 years. Patients younger than 18 years had lower odds of transport (aOR 0.74; 95% CI, 0.73–0.75). Compared to calls occurring between 7 a.m. and 3 p.m., odds of transport were lower between 3 p.m. and 11 p.m. (aOR 0.83; 95% CI, 0.83–0.85) and between 11 p.m. and 7 a.m. (aOR 0.88; 95% CI, 0.87–0.88). Smaller differences in transport rates, likely not clinically significant, were seen for sex, day of week, and fire-based agencies. Conclusion—This analysis encompassing a broad range of EMS systems in various practice settings identified differences in transport rates by agency characteristics, time of day, patient race/ethnicity, and age. Further work is needed to elucidate the underlying causes of these differences for each variable. Limita- tions include information bias due to documentation practices and potential selection bias from analyzing a single PCR provider. Prehospital Use of Ketamine, Morphine, or Fentanyl for the Management of Acute Pain Following Traumatic Injury Author: Jeffrey Jarvis, MD, MS, EMT-P Associate authors: Lauren Curtis, BS, EMT-P Introduction—Ketamine has shown equivalent analge- sia when compared to morphine and fentanyl in hospitalized patients. Objective—To compare the analgesic effects of low-dose ketamine, fentanyl, and morphine in the treatment of acute, traumatic pain in the prehospital setting. Methods—Using data from the ESO Solutions national data- base, we performed a retrospective chart review on all 9-1-1 calls answered by 883 EMS agencies between Jan. 5, 2017, and Dec. 31, 2017, in which patients were treated with ketamine, fentanyl, or morphine following traumatic injury. Patients included were greater than 12 years old, had pain of traumatic etiology, an initial pain score of more than 5, at least one subsequent pain score, and administration of either low-dose ketamine, fentanyl, or morphine. Due to poor weight documentation, low-dose ket- amine was defined as less than 70 mg parenterally. The pri- mary outcome measure was differences in the proportion of patients in each group with a clinically significant reduction in pain, defined as a decrease of more than 1.3 points on the numer- ic rating scale. A chi-square test on the binomial proportion of pain reduction was performed and changes in Glasgow Coma Scale, pulse oximetry, end-tidal CO2, systolic blood pressure, heart rate, and respiratory rate following therapy are discussed. Results—Of 35,906 patients who met inclusion criteria, 28,738 (80.0%) received fentanyl, 6,534 (18.2%) morphine, and 634 (1.8%) ketamine. The following showed a clinically significant reduction in pain: 84.8% in the ketamine group, 85.8% in the fentanyl group, and 83.6% in the morphine group. There was no significant difference in pain when the ketamine group was compared to either the fentanyl group or the morphine group, but fentanyl was associated with clinically significant reduction in pain compared to morphine (p<0.0001). The median single dose of ketamine was 15 mg, fentanyl 50 mcg, and morphine 4 mg. Conclusion—In the prehospital setting ketamine, compared to fentanyl and morphine, was associated with an equivalent proportion of patients with significant pain reduction. Fentanyl, compared to morphine, was associated with a larger proportion of patients with significant pain reduction. Limitations include an inability to calculate weight-based doses and the possibility of underdosing of morphine. EMS Can Safely Predict Large Vessel Occlusions Author: Kim Pelletier, LP, RN Associate authors: Gerad Troutman, MD, FACEP, James C. Curry, LP, Robert D. Henry, EMT-P, Thomas J. Moore, LP Introduction—Patients with large vessel occlusion (LVO) strokes or significant intracranial hemorrhage (ICH) are bet- ter served by direct transport to a hospital with endovascular thrombectomy and neurosurgical capabilities. The VAN scale (visual, aphasia, and neglect) is a new screening tool focusing on early emergency department LVO prediction. Objective—To examine the effectiveness of early VAN scale use in the prehospital setting primarily for LVO. Methods—EMS personnel in a hospital-based 9-1-1 service were trained for three months before VAN use. After implemen- tation a VAN stroke evaluation was required for any patient who met the Cincinnati Stroke Scale criteria for arm drift. Through the hospital's quality improvement process, data were obtained for all patients who tested positive for new or worsening CSS arm drift and were transported to a specific primary stroke center. Patient outcomes were obtained through manual chart review. Results—From July 2017 to January 2018, all 105 prehospital code stroke activations transported to the stroke center were included for the study. Of these 105 patients, 61 (58%) were VAN-positive as determined by the EMS paramedic on scene. Twelve (19.6%) of the VAN-positive patients were later diag- nosed with an LVO through CTA imaging. Eight (7.6%) of the VAN-positive patients were diagnosed with a significant ICH causing cerebral dysfunction. No patient had both an LVO and ICH before hospital intervention. One patient (1.6%) was missed by the VAN tool. For LVO alone the VAN scale showed sensitivity

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