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Can an out-of-hospital cervical spine clearance protocol identify all patients with injuries? An argument for selective immobilization

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ANNALS OF EMERGENCY MEDICINE 2001年第6期37卷 609-615页

作者： Stroh, G Braude, D Calif State Univ Fresno Dept Emergency Med Med Ctr Fresno CA 93740 USA

Study objective: We sought to determine the sensitivity of the Fresno/Kings/Madera emergency medical services (EMS) selective spine immobilization protocol in identifying patients with potential cervical injuries. We also sought to determine whether the protocol was safe in the out-of-hospital setting. Methods: We conducted a retrospective chart review of all patients discharged from 5 trauma-receiving hospitals in Fresno County with the diagnosis of cervical spine injury between July 1, 1990, and June 30, 1996. All of these patients transported to the hospital by EMS personnel were selected for the study group. Medical records of those patients not immobilized were further investigated to identify protocol violations or deficiencies. Results: There were 861 patients with significant cervical injuries during this time span. EMS personnel brought 504 patients to the hospital, of which 495 arrived in cervical spine immobilization. Of: the remaining 9 patients, 2 refused immobilization, and 2 could not be immobilized;3 injuries were missed by the protocol criteria, and 2 injuries were missed because of protocol violations. Of these last 5 patients, 1 patient had an adverse outcome, 2 injuries were considered unstable, 4 patients were older than 67 years, and one patient was 9 months old. Conclusion: The Fresno/Kings/Madera EMS selective spine immobilization protocol is 99% (95% CI, 97.7% to 99.7%) sensitive in identifying patients with cervical injuries far immobilization. Those patients not identified were at extremes of age. These results suggest that selective immobilization may be safely applied in the out-of-hospital setting but should be used with caution at extremes of age.

关键词：年龄因素加利福尼亚颈椎/损伤临床方案/标准急救医疗服务/方法急救医疗服务/标准固位病人遴选回顾性研究安全敏感性与特异性脊髓损伤/分类脊髓损伤/诊断脊髓损伤/治疗脊柱骨折/分类脊柱骨折/诊断脊柱骨折/治疗创伤诊治中心治疗结果青少年成年人老年人老年人 80以上儿童儿童学龄前女(雌)性人类婴儿男(雄)性中年人

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Prognostic accuracy of cerebral blood flow measurement by perfusion computed tomography, at the time of emergency room admission, in acute stroke patients

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ANNALS OF NEUROLOGY 2002年第4期51卷 417-432页

作者： Wintermark, M Reichhart, M Thiran, JP Maeder, P Chalaron, M Schnyder, P Bogousslavsky, J Meuli, R CHU Vaudois Dept Neurol CH-1011 Lausanne Switzerland CHU Vaudois Dept Diagnost & Intervent Radiol CH-1011 Lausanne Switzerland Swiss Fed Inst Technol Signal Proc Lab CH-1015 Lausanne Switzerland

The purpose of this study was to determine the prognostic accuracy of perfusion computed tomography (CT), performed at the time of emergency room admission, in acute stroke patients. Accuracy was determined by comparison of perfusion CT with delayed magnetic resonance (MR) and by monitoring the evolution of each patient's clinical condition. Twenty-two acute stroke patients underwent perfusion CT covering four contiguous 10mm slices on admission, as well as delayed MR, performed after a median interval of 3 days after emergency room admission. Eight were treated with thrombolytic agents. Infarct size on the admission perfusion CT was compared with that on the delayed diffusion-weighted (DWI)MR, chosen as the gold standard. Delayed magnetic resonance angiography and perfusion-weighted MR were used to detect recanalization. A potential recuperation ratio, defined as PRR = penumbra size/(penumbra size + infarct size) on the admission perfusion CT, was compared with the evolution in each patient's clinical condition, defined by the National Institutes of Health Stroke Scale (NIHSS). In the 8 cases with arterial recanalization, the size of the cerebral infarct on the delayed DWI-MR was larger than or equal to that of the infarct on the admission perfusion CT, but smaller than or equal to that of the ischemic lesion on the admission perfusion CT;and the observed improvement in the NIHSS correlated with the PRR (correlation coefficient = 0.833). In the 14 cases with persistent arterial occlusion, infarct size on the delayed DWI-MR correlated with ischemic lesion size on the admission perfusion CT (r = 0.958). In all 22 patients, the admission NIHSS correlated with the size of the ischemic area on the admission perfusion CT (r = 0.627). Based on these findings, we conclude that perfusion CT allows the accurate prediction of the final infarct size and the evaluation of clinical prognosis for acute stroke patients at the time of emergency evaluation. It may also provide infor

关键词：急性病动脉闭塞性疾病/放射摄影术脑血管循环急救医疗服务/标准磁共振成像试验预期值预后前瞻性研究可重复性结果时间因素体层摄影术 X线计算机/标准成年人老年人老年人 80以上女(雌)性人类男(雄)性中年人

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Hydroxocobalamin: Improved public health readiness for cyanide disasters

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ANNALS OF EMERGENCY MEDICINE 2001年第6期37卷 635-641页

作者： Sauer, SW Keim, ME Ctr Dis Control & Prevent Natl Ctr Environm Hlth Atlanta GA 30341 USA Emory Univ Sch Med Dept Emergency Med Atlanta GA USA Univ Hawaii Manoa USA Med Corps Honolulu HI 96822 USA Univ Hawaii Manoa Sch Publ Hlth Honolulu HI 96822 USA

The United Stales is under the constant threat of a mass casualty cyanide disaster from industrial accidents, hazardous material transportation incidents, and deliberate terrorist attacks. The current readiness for cyanide disaster by the emergency medical system in the United States is abysmal. We, as a nation, are simply not prepared for a significant cyanide-related event. The standard of care for cyanide intoxication is the cyanide antidote kit, which is based on the use of nitrites to induce methemoglobinemia. This kit is both expensive and ill suited for out-of-hospital use. It also has its own inherent toxicity that prevents rapid administration. Furthermore, our hospitals frequently fail to stock this life-saving antidote or decline to stock more than one. Hydroxocobalamin is well recognized as an efficacious, safe, and easily administered cyanide antidote. Because of its extremely low adverse effect profile, it is ideal for out-of-hospital use in suspected cyanide intoxication. To effectively prepare for a cyanide disaster, the United States must investigate, adopt, manufacture, and stockpile hydroxocobalamin to prevent needless morbidity and mortality.

关键词：事故职业亚硝酸异戊酯/治疗应用解毒药/供应和分配解毒药/治疗应用化学战氰化物/中毒救灾计划/组织和管理急救医疗服务/方法急救医疗服务/标准急诊处理/方法急诊处理/标准危害物质/中毒羟钴胺/供应和分配羟钴胺/治疗应用需求估价/组织和管理中毒/药物疗法中毒/流行病学中毒/病因学公共卫生工作/标准亚硝酸钠/治疗应用恐怖主义硫代硫酸盐类/治疗应用运输美国/流行病学人类

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Airways in pediatric and newborn resuscitation

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ANNALS OF EMERGENCY MEDICINE 2001年第4期37卷 S126-S136页

作者： Zideman, D Zaritsky, A Carlo, W Osmond, MH Gausche-Hill, M Hazinski, MF Rasmussen, GE Nadkarni, VM Hammersmith Hosp Dept Anesthet London W12 0HS England Childrens Hosp Kings Daughters Norfolk VA USA Univ Alabama Birmingham AL USA Childrens Hosp Eastern Ontario Ottawa ON K1H 8L1 Canada Harbor UCLA Med Ctr Torrance CA 90509 USA Vanderbilt Univ Nashville TN USA AI duPont Hosp Children Wilmington DE USA

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The chain of survival

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ANNALS OF EMERGENCY MEDICINE 2001年第4期37卷 S5-S16页

作者： Jacobs, I Callanan, V Nichol, G Valenzuela, T Mason, P Jaffe, AS Landau, W Vetter, N Univ Western Australia Dept Emergency Med Nedlands WA 6907 Australia Townsville Gen Hosp Townsville Qld Australia Ottawa Civic Hosp Ottawa ON K1Y 4E9 Canada Univ Arizona Tucson AZ USA Natl Heart Fdn New Zealand Christchurch New Zealand SUNY Hlth Sci Ctr Syracuse NY 13210 USA Univ Washington Seattle WA 98195 USA UWCM Cardiff S Glam Wales

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CPR-only survivors of out-of-hospital cardiac arrest: Implications for out-of-hospital care and cardiac arrest research methodology

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ANNALS OF EMERGENCY MEDICINE 2001年第6期37卷 602-608页

作者： De Maio, VJ Stiell, IG Spaite, DW Ward, RE Lyver, MB Field, BJ Munkley, DP Wells, GA Ottawa Hosp Ontario Hlth Res Inst Ottawa ON Canada Univ Ottawa Div Emergency Med Ottawa ON Canada Univ Ottawa Dept Med Ottawa ON Canada Univ Arizona Arizona Emergency Med Res Ctr Tucson AZ USA Joseph Brant Mem Hosp Dept Emergency Med Burlington ON Canada Sunnybrook Base Hosp Program Toronto ON Canada

Study objective: There is little evidence that cardiopulmonary resuscitation (CPR) alone may lead to the resuscitation of cardiac arrest victims with other than respiratory causes (eg, pediatric arrest, drowning, drug overdose). The objective of this study was to identify out-of-hospital cardiac arrest survivors resuscitated without defibrillation or advanced cardiac life support. Methods: This observational cohort included all adult survivors of out-of-hospital cardiac arrest of a cardiac cause from phases I and II of the Ontario Prehospital Advanced life Support Study. During the study period, the system provided a basic life support/defibrillation level of care but no advanced life support. CPR-only patients were patients determined to be without vital signs by EMS personnel who regained a palpable pulse in the field with precordial thump or CPR only and then were admitted alive to the hospital. Six members of a 7-member expert review panel had to rate the patient as either probably or definitely having an out-of-hospital cardiac arrest, and a rhythm strip consistent with a cardiac arrest rhythm had to be present to be considered a patient. Criteria considered were witness status, citizen or first responder CPR, CPR duration, arrest rhythm and rate, and performance of precordial thump. Results: From January 1, 1991,to June 30, 1997, 9,667 patients with out-of-hospital cardiac arrest were treated. The overall survival rate to hospital discharge was 4.6%. There were 97 apparent CPR-only patients admitted to the hospital. Application of the inclusion criteria yielded 24 CPR-only patients who had true out-of-hospital cardiac arrest and 73 patients judged not to have cardiac arrest. Of the 24 true CPR-only patients admitted to the hospital, 15 patients were discharged alive, 10 patients were witnessed by bystanders, and 7 patients were witnessed by EMS personnel. The initial arrest rhythm was pulseless electrical activity in 9 patients, asystole in 12 patients, and ve

关键词：心肺复苏术/方法心肺复苏术/标准队列研究电抗休克心电描记术急救医疗服务/方法急救医疗服务/标准卫生服务研究/方法卫生服务研究/标准心脏停搏/诊断心脏停搏/死亡率心脏停搏/治疗安大略/流行病学触诊存活率分析幸存患者/统计学和数值数据时间因素治疗结果老年人老年人 80以上女(雌)性人类男(雄)性中年人

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Optimal defibrillation response intervals for maximum out-of-hospital cardiac arrest survival rates

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ANNALS OF EMERGENCY MEDICINE 2003年第2期42卷 242-250页

作者： De Maio, VJ Stiell, IG Wells, GA Spaite, DW Univ N Carolina Sch Med Dept Emergency Med Chapel Hill NC 27599 USA Univ Arizona Arizona Emergency Med Res Ctr Dept Emergency Med Tucson AZ USA Ottawa Hlth Res Inst Ottawa ON Canada Univ Ottawa Dept Emergency Med Ottawa ON Canada Univ Ottawa Dept Med Ottawa ON Canada

Study objective: Many centers optimize their emergency medical services (EMS) systems to achieve a target defibrillation response interval of "call received by dispatch" to "arrival at scene by responder with defibrillator" in 8 minutes or less for at least 90% of cardiac arrest cases. The objective of this study was to analyze survival as a function of time to test the evidence for this standard. Methods: This prospective cohort study included all adult, cardiac etiology, out-of-hospital cardiac arrest cases from phases I and II of the Ontario Prehospital Advanced Life Support (OPALS) study. Patients in the 21 Ontario study communities received a basic life support level of care with defibrillation by ambulance and firefighters but no advanced life support. Survival was plotted as a function of the defibrillation response interval. The equation of the curve, generated by means of logistic regression, was used to estimate survival at various defibrillation response interval cutoff points. Results: From January 1, 1991, to December 31, 1997, there were 392 (4.2%) survivors overall among the 9,273 patients treated. The defibrillation response interval mean was 6.2 minutes, and the 90th percentile was 9.3 minutes. There was a steep decrease in the first 5 minutes of the survival curve, beyond which the slope gradually leveled off. Controlling for known covariates, the decrement in the odds of survival with increasing response interval was 0.77 per minute (95% confidence interval 0.74 to 0.83). The survival function predicts, for successive 90th percentile cutoff points, both survival rates and additional lives saved per year in the OPALS communities compared with the 8-minute standard: 9 minutes (4.6%;-18 lives), 8 minutes (5.9%;0 lives), 7 minutes (7.5%;23 lives), 6 minutes (9.5%;51 lives), and 5 minutes (12.0%;86 lives). Conclusion: The 8-minute target established in many communities is not supported by our data as the optimal EMS defibrillation response Interval for

关键词：电抗休克/方法电抗休克/标准急救医疗服务/方法急救医疗服务/标准心脏停搏/并发症心脏停搏/病因学心脏停搏/死亡率心脏停搏/治疗生命支持疗法/方法生命支持疗法/标准 Logistic模型多元分析比值比安大略/流行病学诊疗准则(主题) 试验预期值前瞻性研究危险因素季节存活率心动过速室性/并发症时间因素治疗结果心室颤动/并发症成年人老年人女(雌)性人类男(雄)性中年人

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Practice guidelines and performance measures in emergency medical services for children

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ANNALS OF EMERGENCY MEDICINE 2002年第4期39卷 404-412页

作者： Moody-Williams, JD Krug, S O'Connor, R Shook, JE Athey, JL Holleran, RS Natl Resource Ctr EMSC Washington DC 20010 USA Chicago Childrens Mem Hosp Div Emergency Med Chicago IL USA Med Ctr Delaware Newark DE USA Baylor Coll Med Dept Pediat Emergency Med Houston TX 77030 USA Dept Hlth & Human Serv Maternal & Child Hlth Bur Rockville MD USA Emergency Nurses Assoc Milford OH USA

Practice guidelines and performance measures are critical elements of an effective quality improvement process for emergency medical services for children (EMSC). Practice guidelines address the clinical management of individual patients, and performance measures assess the quality of care delivered to a population. The public and private sectors have invested considerable resources in developing practice guidelines and performance measures to improve the quality of health care services, As organizations continue development efforts, health care professionals who are actively involved in emergency care must collaborate to develop guidelines that address the unique physiologic, psychologic, and cultural needs of children. The Emergency Medical Services for Children Managed Care Task Force recommended the development of a series of white papers to focus on issues related to practice guidelines and performance measures in EMSC. The Maternal and Child Health Bureau, Health Resources and Services Administration, the National Highway Traffic Safety Administration, and the Robert Wood Johnson Foundation jointly sponsored the project. The paper was developed by a panel selected from a pool of experts in managed care, quality improvement, and emergency medical services. After a review of the literature, the panelists met to discuss critical issues related to practice guidelines and performance measures in EMSC. The panelists developed recommendations that can serve as resources for managed care organizations, health care providers, professional associations, and governmental policy makers. The panel recognized the lack of nationally recognized pediatric emergency care guidelines and performance measures and called for immediate action in these areas.

关键词：儿童保健服务/标准急救医疗服务/标准循证医学/方法卫生人员/教育卫生人员/标准政策制订诊疗准则(主题) 职业家庭关系质量指标卫生保健美国儿童人类

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Ethics in emergency cardiac care

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ANNALS OF EMERGENCY MEDICINE 2001年第4期37卷 S196-S200页

作者： Abramson, N de Vos, R Fallat, ME Finucane, T Kettler, D Pepe, P Steen, PA Strobos, NC Univ Pittsburgh Pittsburgh PA USA Univ Amsterdam Amsterdam Netherlands Univ Louisville Louisville KY 40292 USA Johns Hopkins Univ Sch Med Baltimore MD USA Univ Gottingen D-3400 Gottingen Germany Univ Texas SW Med Sch Dallas TX 75230 USA Univ Oslo Oslo Norway

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Accuracy and clinical effect of out-of-hospital electrocardiography in the diagnosis of acute cardiac ischemia: A meta-analysis

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ANNALS OF EMERGENCY MEDICINE 2001年第5期37卷 461-470页

作者： Ioannidis, JPA Salem, D Chew, PW Lau, J New England Med Ctr Div Clin Care Res Evidence Based Practice Ctr Boston MA 02111 USA

Study objective: We sought to evaluate quantitatively the evidence on the diagnostic performance of out-of-hospital ECG for the diagnosis of acute cardiac ischemia (ACI) and acute myocardia[ infarction (AMI) and the clinical effect of out-of-hospital thrombolysis. Methods: We conducted a systematic review and meta-analysis of the English-language literature published between 1966 and December 1998 on the diagnostic accuracy of out-of-hospital ECG and the clinical effect of out-of-hospital thrombolysis. Both prospective and retrospective studies qualified for the assessment of diagnostic performance. For clinical effect, data from prospective nonrandomized studies were synthesized separately from data from randomized trials. Diagnostic performance was assessed by using estimates of test sensitivity, specificity and diagnostic odds ratios and was summarized by using summary receiver-operating characteristic curves, Measures of clinical effect included time savings, early ventricular function, early mortality, and long-term survival. Results: Diagnostic accuracy was evaluated in 11 studies with a total of 7,508 patients. Data were available for ACI in 5 studies and for AMI in 8 studies. For ACI, the random-effects pooled sensitivity was 76% (95% CI, 54% to 89%), the specificity was 88% (95% CI, 67% to 96%), and the diagnostic odds ratio was 23 (95% CI, 6.3 to 85). The respective figures for AMI were sensitivity of 68% (95% CI, 59% to 76%), specificity of 97% (95% CI, 89% to 92%), and diagnostic odds ratio of 104 (95% CI, 48 to 224). Both in nonrandomized (n=4, total 1,531 patients) and randomized (n=9, total 6,643 patients) studies, out-of-hospital thrombolysis shortened the time from onset of symptoms to thrombolytic treatment by 40 to 60 minutes. Data on shortterm ejection fraction were sparse. Hospital mortality was reduced by 16% (95% CI, 2% to 27%) among randomized trials, and a similar estimate of effect was seen in nonrandomized studies. There was no clear effec

关键词：急性病偏倚(流行病学) 心电描记术/标准急救医疗服务/方法急救医疗服务/标准循证医学纤维蛋白溶解药/治疗应用医院死亡率心肌梗死/诊断心肌梗死/药物疗法心肌梗死/死亡率心肌缺血/诊断心肌缺血/药物疗法心肌缺血/死亡率比值比前瞻性研究可重复性结果研究设计回顾性研究敏感性与特异性存活率分析时间因素治疗结果心室功能/药物作用人类

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