BACKGROUND & AIMS: :Prehospital advanced trauma life support (ATLS) is controversial because the risks, benefits, and time required to accomplish it remain unknown. We studied 70 consecutive patients with penetrating cardiac injuries to determine the relationships among prehospital procedures, time consumed in the field, and ultimate patient outcome. Thirty-one patients sustained gunshot wounds, and 39 had stab wounds. The mean Revised Trauma Score was 2.8 +/- 0.5. Paramedics spent an average of 10.7 +/- 0.5 minutes at the scene. Seventy-one percent of the patients underwent endotracheal intubation; 93% had at least one IV line inserted; and 57% had two IV lines inserted. Twenty-one (30%) survived. There was no correlation between on-scene time and either the total number of procedures performed (r = .17, P = .17) or IV lines established (r = .06, P = .6). On-scene times did not differ regardless of whether endotracheal intubation or pneumatic antishock garment applications occurred. We conclude that well-trained urban paramedics can perform multiple life-support procedures with very short on-scene times and a high rate of patient survival and that prehospital trauma systems require a minimum obligatory on-scene time to locate patients and prepare them for transport.

背景与目标： : 院前高级创伤生命支持 (ATLS) 是有争议的，因为完成它所需的风险，收益和时间仍然未知。我们研究了70例连续的穿透性心脏损伤患者，以确定院前手术，现场时间消耗和最终患者预后之间的关系。31名患者受枪伤，39名有刺伤。平均修订创伤评分为2.8 +/- 0.5。医护人员在现场平均花费10.7 +/- 0.5分钟。1% 的患者接受了气管插管; 93% 插入了至少一条静脉输液管; 57% 插入了两条静脉输液管。二十一 (30%) 幸存下来。现场时间与所执行的程序总数 (r = .17，P = .17) 或所建立的IV线 (r = .06，P = .6) 之间没有相关性。无论是否发生气管插管或气动抗冲击服装应用，现场时间都没有差异。我们得出的结论是，训练有素的城市护理人员可以执行多个生命支持程序，现场时间非常短，患者生存率很高，并且院前创伤系统需要最少的强制性现场时间来定位患者并为他们做好准备运输。

BACKGROUND & AIMS: INTRODUCTION:Exposure to cold temperature is a serious but often neglected problem in prehospital care. It not only is an uncomfortable, subjective experience, but it also can cause severe disturbances in vital functions, gradually leading to hypothermia. OBJECTIVE:The aim of this study was to examine healthy subjects' physiological and subjective reactions to cold exposure (30 minutes at -5 degrees C in the a climatic chamber) while they were lying in a protective covering. METHODS:Healthy volunteers (n = 20) participated in the experiment, which consisted of a 10-minute stabilization period of vital functions at room temperature (23 degrees C), 30 minutes of cold exposure (-5 degrees C), and a 30-minute recovery period at room temperature. Subjects lay supinely in protective covering during the entire experiment. Skin temperatures, oxygen saturation, pulse rates, pulse wave amplitude in the middle finger, and surface electromyography (EMG) activity of the major pectoral muscle were recorded continuously during the test. Before and immediately after the cold exposure, tympanic membrane temperatures were measured. In addition, subjects were asked to estimate cold using a standard scale. RESULTS:During the cold exposure, the decrease in tympanic membrane temperature was not significant. The pulse wave amplitude in the finger decreased sharply upon entering the cold chamber. Skin temperatures, especially of the fingers and toes, decreased during the cold exposure. There were no clear signs of shivering in electromyographic recordings. Subjective cold feelings followed decreasing skin temperatures. Skin temperatures did not return quickly. Even 30 minutes after the exposure, all the skin temperatures still had not returned to normal levels. However, subjective cold feeling was relieved immediately. CONCLUSIONS:Cold exposure provoked immediate protective vasoconstriction in the peripheral compartment, which caused linear decreases of local skin temperatures. This probably was triggered from the unprotected face and upper respiratory areas.

背景与目标：

BACKGROUND & AIMS: OBJECTIVE:Analgesia in the prehospital setting is an extremely important, yet controversial topic. Ketamine, a N-methyl D-aspartate (NMDA) receptor antagonist, has been commonly used in the prehospital setting, including recommendations by the US Department of Defense and by the Royal Australian College of Pain Medicine, despite the paucity of high-level evidence. METHODS:Accordingly, a review of the literature was conducted using several electronic medical literature databases from the earliest available records to the time at which the search was conducted (October 2018). RESULTS:The search strategy yielded a total of 707 unique papers, of which 43 were short-listed for full review, and ultimately, ten papers were identified as meeting all the relevant inclusion criteria. The included studies varied significantly in the prehospital context and in the means of administering ketamine. There was only low-grade evidence that ketamine offered a safe and effective analgesia when used as the only analgesic, and only low-grade evidence that it was as effective as alternative opioid options. However, there was moderate evidence that co-administration of ketamine with morphine may improve analgesic efficacy and reduce morphine requirement. CONCLUSIONS:Overall, ketamine as a prehospital analgesic may be best used in combination with opioids to reduce opioid requirement. It is suggested that future studies should use a standardized approach to measuring pain reduction. Future studies should also investigate short-term side effects and long-term complications or benefits of prehospital ketamine.

背景与目标：

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.

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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.

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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.

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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.

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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.

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