BACKGROUND & AIMS: OBJECTIVE:To investigate the end-of-life decision process in patients managed by emergency physicians in the prehospital setting. DESIGN:A 40-item retrospective study about most recent end-of-life decision in the prehospital setting. PATIENTS AND PARTICIPANTS:1069 physicians (44.9%) from 192 French emergency mobile units. MEASUREMENTS AND RESULTS:A total of 816 (76.3%) physicians reported at least one prehospital end-of-life decision. Conscious patients were involved in 30.7% (54/176) and families in 63.6% of cases. The physician discussed the end-of-life decision with at least one other physician in 56.5% of cases. Perceived imminent death was the most frequently reported criterion (90.1%). Nearly four fifths of patients died before arrival at the hospital (78.8%). Factors independently associated with prehospital withdrawal decision included multiple trauma [odds ratio (OR) 5.7, 95% confidence interval (CI) 1.6-19.7], intubation (OR 3.9, 95% CI 2.3-6.5), chronic disease with severe heart failure (OR 2.8, 95% CI 1.5-5.2), acute event with postanoxic coma (OR 2.2, 95% CI 1.3-4.0), emergency physician from a teaching hospital (OR 2.1, 95% CI, 1.3-3.5), male patient (OR 1.9, 95% CI 1.1-3.3), and no sedation (OR 1.9, 95% CI 1.2-3.1). Prehospital withholding decisions were taken for 684 (88%) patients and withdrawing decisions for 12%. CONCLUSIONS:Treatment withholding and withdrawal is common in the prehospital setting in France. These decisions remain highly questionable in this emergency context, in the absence of knowledge of the patient's medical history and of patients' and relatives' clear wishes concerning end-of-life decisions.

背景与目标：

BACKGROUND & AIMS: Background:Hydroxyethyl starch (Hextend) has been used for hemorrhagic shock resuscitation, however, hydroxyethyl starch may be associated with adverse outcomes. Objective:To compare systolic blood pressure (sBP) in animals that had 30% of their blood volume removed and treated with intravenous hydroxocobalamin, hydroxyethyl starch, or no fluid. Methods:Twenty-eight swine (45-55 kg) were anesthetized and instrumented with continuous femoral and pulmonary artery pressure monitoring. Animals were hemorrhaged 20 mL/kg over 20 minutes and then administered 150 mg/kg IV hydroxocobalamin in 180 mL saline, 500 mL hydroxyethyl starch, or no fluid and monitored for 60 minutes. Data were modeled using repeated measures multivariate analysis of variance. Results:There were no significant differences before treatment. At 20 minutes after hemorrhage, there was no significant difference in mean sBP between treated groups, however, control animals displayed significantly lower mean sBP (p < 0.001). Mean arterial pressure and heart rate improved in the treated groups but not in the control group (p < 0.02). Prothrombin time was longer and platelet counts were lower in the Hextend group (p < 0.05). Moreover, thromboelastography analysis showed longer clotting (K) times (p < 0.05) for the hydroxyethyl starch-treated group. Conclusion:Hydroxocobalamin restored blood pressure more effectively than no treatment and as effectively as hydroxyethyl starch but did not adversely affect coagulation.

背景与目标：

BACKGROUND & AIMS: OBJECTIVE:To evaluate the accuracy of Internet information regarding the prehospital care of venomous snake bites. METHODS:Two major search engines were used to identify 48 Web sites regarding 6 prehospital treatment options for snake bite (removal of constrictive devices, ice, heat, electric shock, incision, and suction). Web sites were evaluated for their quality using the Health on the Net (HON) seal and Journal of the American Medical Association (JAMA) benchmarks. RESULTS:Of the 48 Web sites reviewed, 26 (54.1%) contained inappropriate recommendations. The remaining 22 Web sites were appropriate regarding all modalities addressed. Among the Web sites reviewed, inappropriate treatment recommendations included: suction (14); ice (6); incision (4); electric shock (1). Five Web sites that met all 4 JAMA benchmarks and the HON seal included 3 inappropriate treatment recommendations. Conversely, the 5 Web sites that met none of the JAMA benchmarks nor included the HON seal included only 2 inappropriate treatment measures. CONCLUSION:This study highlights the variety of misinformation available on the Internet regarding prehospital care of snake bites, and the unreliability of the HON seal and JAMA benchmarks as markers of accuracy. As the Internet becomes an increasing source of medical information for both the public and clinicians, the importance of accurate Web sites becomes imperative. Clinicians and lay people should be aware of the high variability of Internet information regarding snake bite prehospital care.

背景与目标：

BACKGROUND & AIMS: :Excited delirium syndrome (ExDS) is a medical emergency usually presenting first in the prehospital environment. Untreated ExDS is associated with a high mortality rate and is gaining recognition within organized medicine as an emerging public safety problem. It is highly associated with male gender, middle age, chronic illicit stimulant abuse, and mental illness. Management of ExDS often begins in the field when first responders, law enforcement personnel, and emergency medical services (EMS) personnel respond to requests from witnesses who observe subjects exhibiting bizarre, agitated behavior. Although appropriate prehospital management of subjects with ExDS is still under study, there is increasing awareness of the danger of untreated ExDS, and the danger associated with the need for subject restraint, whether physical or chemical. We describe two ExDS patients who were successfully chemically restrained with ketamine in the prehospital environment, and who had good outcomes without complication. These are among the first case reports in the literature of ExDS survival without complication using this novel prehospital sedation management protocol. This strategy bears further study and surveillance by the prehospital care community for evaluation of side effects and unintended complications.

背景与目标： : 兴奋性谵妄综合征 (ExDS) 是一种医疗紧急情况，通常在院前环境中首先出现。未经治疗的ExDS与高死亡率相关，并且在组织医学中作为新兴的公共安全问题而获得认可。它与男性，中年，慢性非法兴奋剂滥用和精神疾病高度相关。当急救人员，执法人员和紧急医疗服务 (EMS) 人员响应目击者的要求时，通常会开始对exd进行管理，这些目击者观察到表现出怪异，激动的行为。尽管仍在研究对患有ExDS的受试者进行适当的院前管理，但人们越来越意识到未经治疗的ExDS的危险，以及与对受试者进行物理或化学约束有关的危险。我们描述了两名ExDS患者，他们在院前环境中成功地用氯胺酮进行了化学抑制，并且结局良好，没有并发症。这些是使用这种新颖的院前镇静管理方案的ExDS生存无并发症文献中的第一例报告。该策略需要院前护理社区进行进一步的研究和监视，以评估副作用和意外并发症。

BACKGROUND & AIMS: BACKGROUND:Emergency medical services are an important part of acute stroke management. We devised a prehospital stroke scale, the TOYOTA prehospital stroke scale for tissue plasminogen activator (t-PA) intravenous therapy (TOPSPIN) for triaging patients with ischemic stroke and especial indications for intravenous t-PA therapy in December 2006; this scale comprises 5 items including consciousness, atrial fibrillation, language disorder, disturbance of the upper extremities, and disturbance of the lower extremities. The aim of this study was to analyze the results of 10 years of TOPSPIN implementation and to distinguish ischemic stroke from hemorrhagic stroke in the real world. METHODS:We prospectively enrolled consecutive patients who were transferred to our hospital and evaluated by Toyota city ambulance services using the TOPSPIN from December 2006 to January 2017. We examined definite diagnosis at the time of hospital discharge (ischemic stroke, hemorrhagic stroke, or stroke mimic), positive-predictive value of the stroke, the rate of the recanalization therapy, and clinical differentiation among patients with hemorrhagic stroke, ischemic stroke, and stroke mimics. RESULTS:A total of 1,482 consecutive patients were enrolled; 1,134 (76.5%) were patients with stroke (628 ischemic-type, 34 transient ischemic attack-type, and 472 hemorrhagic-type) and 348 (23.5%) without stroke (80 with seizure, 42 with syncope, 27 with hypoglycemia, and 199 other). Among 628 patients with ischemic stroke, 130 (20.7%) received intravenous recombinant t-PA treatment, endovascular therapy, or both. The presence of atrial fibrillation, older age, lower blood pressure, and lower total TOPSPIN score was more commonly associated with ischemic stroke than with hemorrhagic stroke. In multivariable logistic regression analysis, the presence of atrial fibrillation was independently associated with ischemic stroke (OR 2.33; 95% CI 1.61-3.40). CONCLUSIONS:The TOPSPIN is a simple prehospital stroke scale that includes an assessment of atrial fibrillation. Detection of atrial fibrillation in the prehospital stage may point to a higher probability of ischemic stroke.

背景与目标：

BACKGROUND & AIMS: BACKGROUND:To date, attempts to assess the relationship between motor vehicle collision (MVC)-related mortality and medical resources availability have largely been unsuccessful. METHODS:Information regarding sociodemographic characteristics, prehospital resources, and hospital-based resources for each county (n = 67) in the state of Alabama was obtained. MVC-related mortality rates (deaths per 1,000 collisions) by county were calculated and compared according to prehospital and hospital-based resource availability within each county after correcting for sociodemographic factors. RESULTS:Counties with 24-hour availability of a general surgeon, orthopedic surgeon, neurosurgeon, computed tomographic scanner, and operating room were shown to have decreased MVC-related mortality (relative risk [RR], 0.88). The same was true for those counties with hospitals classified as Level I-II (RR, 0.71) and Level III-IV (RR, 0.83) trauma centers compared with counties with no trauma centers. CONCLUSION:Appropriate, readily available hospital-based resources are associated with lower MVC-related mortality rates. This information may be useful in trauma system planning and development.

背景与目标：

BACKGROUND & AIMS: :Informed consent to participation in research is an important protector of potential subjects' rights and autonomy. Ethical research involving critically ill people is challenging because their medical condition often makes obtaining informed consent impossible. This is especially true in the prehospital setting, where additional barriers to obtaining informed consent exist. A recently published Canadian policy (Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans) specifies circumstances under which an exception to the requirement for informed consent may be granted so that vulnerable individuals are not denied the potential benefits of participating in research. This article reviews the rationale for the Tri-Council Policy Statement and illustrates some problems with its application in the context of a Canadian prehospital study on continuous positive airway pressure. A new risk analysis model and a national research ethics board are discussed as possible ways to facilitate interpretation and application of the current exception of informed consent policy.

背景与目标： : 知情同意参与研究是潜在受试者权利和自主权的重要保护者。涉及重症患者的伦理研究具有挑战性，因为他们的医疗状况通常使获得知情同意成为不可能。在院前环境中尤其如此，因为在获得知情同意方面存在其他障碍。加拿大最近发布的一项政策 (三理事会政策声明: 涉及人类的研究的道德行为) 规定了在何种情况下可以给予知情同意要求的例外，以便弱势群体不会被剥夺参与研究的潜在好处。本文回顾了Tri-Council政策声明的基本原理，并说明了在加拿大对持续气道正压的院前研究中应用该声明的一些问题。讨论了一种新的风险分析模型和国家研究伦理委员会，作为促进当前知情同意政策例外的解释和应用的可能方法。

BACKGROUND & AIMS: BACKGROUND:Despite the effectiveness of timely reperfusion therapy for acute coronary syndrome, prehospital delay remains a global concern. OBJECTIVE:This article assesses the state-of-the-science regarding prehospital delay for acute coronary syndrome in China. METHOD:Electronic databases and hand searching were undertaken using key words such as prehospital delay, care-seeking delay, coronary heart disease, heart disease, acute coronary syndrome, unstable angina pain, acute myocardial infarction, cardiovascular disease, chest pain, and Chin (China/Chinese). The Chinese search was supervised by a Chinese health librarian. RESULTS:Based on the search criteria, 28 studies were identified and reviewed using a standardized data extraction tool. Older age, attribution of symptoms to noncardiac causes, lack of health insurance coverage, poor access to transportation, and female sex were identified as contributing to prehospital delay. CONCLUSION:Health system reforms in China are necessary, particularly with regard to addressing the needs of older people, women, and other vulnerable populations in the context of the rising number of people with coronary heart disease. Developing targeted strategies, learned from both national and international experience, are required to develop targeted interventions.

背景与目标：

BACKGROUND & AIMS: BACKGROUND:Prehospital oligoanalgesia is prevalent among trauma victims, even when the emergency medical services team includes a physician. We investigated if not only patients' characteristics but physicians' practice variations contributed to prehospital oligoanalgesia. METHODS:Patient records of conscious adult trauma victims transported by our air rescue helicopter service over 10 yr were reviewed retrospectively. Oligoanalgesia was defined as a numeric rating scale (NRS) >3 at hospital admission. Multilevel logistic regression analysis was used to predict oligoanalgesia, accounting first for patient case-mix, and then physician-level clustering. The intraclass correlation was expressed as the median odds ratio (MOR). RESULTS:A total of 1202 patients and 77 physicians were included in the study. NRS at the scene was 6.9 (1.9). The prevalence of oligoanalgesia was 43%. Physicians had a median of 5.7 yr (inter-quartile range: 4.2-7.5) of post-graduate training and 27% were female. In our multilevel analysis, significant predictors of oligoanalgesia were: no analgesia [odds ratio (OR) 8.8], National Advisory Committee for Aeronautics V on site (OR 4.4), NRS on site (OR 1.5 per additional NRS unit >4), female physician (OR 2.0), and years of post-graduate experience [>4.0 to ≤5.0 (OR 1.3), >3.0 to ≤4.0 (OR 1.6), >2.0 to ≤3.0 (OR 2.6), and ≤2.0 yr (OR 16.7)]. The MOR was 2.6, and was statistically significant. CONCLUSIONS:Physicians' practice variations contributed to oligoanalgesia, a factor often overlooked in analyses of prehospital pain management. Further exploration of the sources of these variations may provide innovative targets for quality improvement programmes to achieve consistent pain relief for trauma victims.

背景与目标：

BACKGROUND & AIMS: :The aim of this project was to promote internationalisation of prehospital education collaboratively between students and teachers from EMS Education and Training, Montana, USA, and Monash University Centre for Ambulance and Paramedic Studies (MUCAPS), Victoria, Australia. The project required students and teachers to engage in a series of face to face lectures, which was reinforced through distance education strategies, such as online learning. The overall project aim was to establish an objective and descriptive view of the internationalisation of prehospital and community based emergency health education using e-learning as the educational approach. A cross sectional survey design using paper based evaluation was adopted in this project. Results revealed a positive student reaction, with flexible pedagogical processes broadening student learning and facilitating an international dimension otherwise not achievable. Given the current state of globalisation, internationalisation has the capacity to improve educational standards, quality, student interactions and specific learning outcomes in prehospital education.

背景与目标： : 该项目的目的是促进来自美国蒙大拿州EMS教育和培训的学生和教师与澳大利亚维多利亚州莫纳什大学救护车和护理人员研究中心 (MUCAPS) 之间的院前教育国际化。该项目要求学生和教师参加一系列面对面的讲座，这些讲座通过远程教育策略得到加强，例如在线学习。整个项目的目的是建立一个客观和描述性的观点，以电子学习为教育方法的院前和社区为基础的紧急健康教育的国际化。该项目采用基于纸质评估的横断面调查设计。结果显示出积极的学生反应，灵活的教学过程扩大了学生的学习范围，并促进了国际范围，否则无法实现。鉴于全球化的现状，国际化有能力提高院前教育中的教育水平，质量，学生互动和特定的学习成果。

BACKGROUND & AIMS: INTRODUCTION:Mexico City has one of the highest mortality rates in Mexico, with non-intentional injuries as a leading cause of death among persons 1-44 years of age. Emergency medical services (EMS) in Mexico can achieve high levels of efficiency by offering high quality medical care at a low cost through adequate system design. OBJECTIVE:The objective of this study was to determine whether the prehospital EMS system in Mexico City meets the criteria standards established by the American Ambulance Association Guide for Contracting Emergency Medical Services (AAA Guide) for highly efficient EMS systems. METHODS:This retrospective, descriptive study, evaluated the structure of Mexico City's EMS system and analyzed EMS response times, clinical capacity, economic efficiency, and customer satisfaction. These results were compared with the AAA guide, according to the soc ial, economic, and political context in Mexico. This paper describes the healthcare system structure in Mexico, followed by a description of the basic structure of EMS in Mexico City, and of each tenet described in the AAA guide. The p aper includesdata obtained from official documents and databases of government agencies, and operative and administrative data from public and private EMS providers. RESULTS:The quality of the data for response times (RT) were insufficient and widely varied among providers, with a minimum RT of 6.79 minutes (min) and a maximum RT of 61 min. Providers did not define RT clearly, and measured it with averages, which can hide potentially poor performance practices. Training institutions are not required to follow a standardized curriculum. Certifications are the responsibility of the individual training centers and have no government regulation. There was no evidence of active medical control involvement in direct patient care, and providers did not report that quality assurance programs were in place. There also are limited career advancement opportunities for EMS personnel. Small economies of scale may not allow providers to be economically efficient, unit hours are difficult to calculate, and few economic data are available. There is no evidence of customer satisfaction data. CONCLUSIONS:Emergency medical services in Mexico City did not meet the AAA requirements for high-quality, prehospital, emergency care. Coordination among EMS providers is difficult to achieve, due, in part, to the lack of: (1) an authoritative structure; (2) sound system design; and (3) appropriate legislation. The government, EMS providers, stakeholders, and community members should work together to build a high quality EMS system at the lowest possible cost.

背景与目标：

BACKGROUND & AIMS: OBJECTIVE:Care in prehospital emergencies presents differences in terms of safety with respect to that provided in the hospital setting, generating situations of high vulnerability in patients. Vulnerability is intimately related to the possibility of experiencing an adverse event. Currently, there is no validated system to evaluate this issue. The aim of this study was to design and validate an instrument to determine the level of vulnerability of patients treated in the emergency prehospital care. METHODS:A clinimetric validation study was conducted in patients who attended prehospital emergency services. RESULTS:An eight-item instrument with adequate content validity (0.93) was designed and empirically tested in a sample of 549 subjects (50.1% men and 49.9% women) with an average age of 61.56 years (standard deviation = 19.76). Cronbach α was 0.81, with a good interitem and item-total correlation and interobserver reliability, with an intraclass correlation coefficient of 0.90 (95% confidence interval = 0.87-0.93). The exploratory factor analysis identified a bifactorial model that explained 61.27% of the total variance, corroborated by confirmatory factor analysis (goodness-of-fit index = 0.97, normed fit index = 0.96, TLI = 0.92, and root mean square error of approximation = 0.093). Instrument scores showed a moderate and significant positive correlation with the age of the subjects (r = 0.31). CONCLUSIONS:The instrument shows a good reliability and validity for its use in the environment of prehospital emergency services, with a structure composed of a group of items related to condition characteristics safety (consciousness, patient communication, risk factors, and patient coping), and mobility, and a second factor including respiratory and medical interventions safety.

背景与目标：

BACKGROUND & AIMS: :Although primary percutaneous coronary intervention has emerged as the preferred reperfusion strategy for patients with ST-segment elevation myocardial infarction (STEMI), it is available only in a minority of US hospitals. The fundamental problem is that there is presently no organized, uniform, national STEMI triage and treatment system that is comparable to the well-developed, highly successful system in the United States that directs major trauma victims to verified trauma centers. This article reviews prehospital and emergency department triage strategies, systems, and pharmacologic interventions for patients with STEMI that can help shorten the time to reperfusion in these patients.

背景与目标： : 尽管原发性经皮冠状动脉介入治疗已成为ST段抬高型心肌梗死 (STEMI) 患者的首选再灌注策略，但仅在美国少数医院中可用。根本的问题是，目前没有一个有组织的，统一的，国家STEMI分诊和治疗系统可以与美国发达的，非常成功的系统相媲美，该系统将主要的创伤受害者引导到经过验证的创伤中心。本文回顾了STEMI患者的院前和急诊科分诊策略，系统和药物干预措施，这些措施可以帮助缩短这些患者的再灌注时间。

BACKGROUND & AIMS: :Fractures of the pelvic ring are a potential source of significant bleeding. Pelvic circumferential compression devices (PCCDs) can reduce and immobilize unstable fractures, but their hemostatic effect is unproven. Our aim was to assess the current practice of prehospital PCCD application and to identify factors available in the field predictive of significant pelvic ring injuries. All interventions (n = 13,435) in the Lausanne University Hospital Emergency Medical Service (EMS) were screened for PCCD placements from January 2008 to November 2014. Significant pelvic ring injuries (Tile types B or C) were considered as potentially benefitting from a PCCD. Data were extracted from the local prehospital registry. During the study period, 2366 trauma missions were performed. A PCCD was applied to 552/2366 (23%) patients. Significant pelvic ring injuries were present in 105/2366 (4.4%). Factors associated with the presence of significant pelvic ring injury were increased respiratory rate (OR 1.04), prolonged capillary refill time (OR 2.11), increased shock index (OR 3.91), pedestrians hit by a vehicle (OR 2.19), and presenting with falls from more than 2 m (OR 1.91). Among patients with a significant pelvic ring injury, a PCCD was placed in 79 (75%) and omitted in 26 (25%). One sixth of patients with a PCCD had a final diagnosis of significant pelvic ring injury. Further studies are needed to better understand which patient-, or accident-related factors are associated with prehospital PCCD omission among patients with significant pelvic ring injury.

背景与目标： 骨盆环骨折是严重出血的潜在来源。骨盆周压装置 (PCCDs) 可以减少和固定不稳定的骨折，但其止血效果尚未得到证实。我们的目的是评估院前PCCD应用的当前实践，并确定可预测严重骨盆环损伤的领域中可用的因素。从2008年1月到2014年11月，对洛桑大学医院急诊医疗服务 (EMS) 的所有干预措施 (n   =   13,435) 进行了PCCD安置筛查。严重的骨盆环损伤 (B或C型瓷砖) 被认为可能受益于PCCD。数据从当地院前登记处提取。在研究期间，进行了2366次创伤检查。将PCCD应用于552/2366 (23%) 患者。105/2366 (4.4%) 存在明显的骨盆环损伤。与存在明显的骨盆环损伤相关的因素包括呼吸频率增加 (或1.04)，毛细血管再充盈时间延长 (或2.11)，休克指数增加 (或3.91)，行人被车辆 (或2.19) 击中，以及从2 m (或1.91) 以上跌倒。在患有严重骨盆环损伤的患者中，在79 (75%) 中放置了PCCD，在26 (25%) 中省略了PCCD。六分之一的PCCD患者最终诊断为严重的骨盆环损伤。需要进一步的研究，以更好地了解在严重骨盆环损伤的患者中，哪些与患者或事故相关的因素与院前pcccd遗漏有关。

BACKGROUND & AIMS: :This article analyses and presents a survey of ethical conflicts in prehospital emergency care. The results are based on six focus group interviews with 29 registered nurses and paramedics working in prehospital emergency care at three different locations: a small town, a part of a major city and a sparsely populated area. Ethical conflict was found to arise in 10 different nodes of conflict: the patient/carer relationship, the patient's self-determination, the patient's best interest, the carer's professional ideals, the carer's professional role and self-identity, significant others and bystanders, other care professionals, organizational structure and resource management, societal ideals, and other professionals. It is often argued that prehospital care is unique in comparison with other forms of care. However, in this article we do not find support for the idea that ethical conflicts occurring in prehospital care are unique, even if some may be more common in this context.

背景与目标： : 本文对院前急救中的伦理冲突进行了分析和调查。结果基于对29名注册护士和医护人员的六次焦点小组访谈，这些护士和医护人员在三个不同的地点从事院前急救工作: 一个小镇，一个主要城市的一部分和一个人口稀少的地区。在10个不同的冲突节点中发现了道德冲突: 患者/照顾者关系，患者的自决，患者的最大利益，照顾者的职业理想，照顾者的职业角色和自我认同，重要的他人和旁观者，其他护理专业人员，组织结构和资源管理、社会理想和其他专业人员。人们经常争辩说，与其他形式的护理相比，院前护理是独特的。但是，在本文中，我们没有找到支持院前护理中发生的道德冲突是独特的观点的支持，即使在这种情况下某些冲突可能更为普遍。