Chest Compressions

• Blood flow forward into the artery and backward into the vein during chest compression in out-of-hospital cardiac arrest. Open Access

• Association between left ventricular outflow tract opening and successful resuscitation after cardiac arrest

Airway Management 

• Regurgitation and pulmonary aspiration during cardio-pulmonary resuscitation (CPR) with a laryngeal tube: A pilot crossover human cadaver study. Open Access.

• Pre-hospital advanced airway management for adults with out-of-hospital cardiac arrest: nationwide cohort study. Open Access

• Confirmed cardiac output on emergency medical services arrival as confounding by indication: an observational study of prehospital airway management in patients with out-of-hospital cardiac arrest. Open Access

• Advanced airway management in out of hospital cardiac arrest: A systematic review and meta-analysis

Pulse Check

• The POCUS pulse check: A randomized controlled crossover study comparing pulse detection by palpation versus by point-of-care Ultrasoundound

• A series of case studies on detection of spontaneous pulse by photoplethysmography in cardiopulmonary resuscitation. Open Access

Cath Lab

• The Evolving Role of the Cardiac Catheterization Laboratory in the Management of Patients With Out-of-Hospital Cardiac Arrest. Open Access

• Coronary Angiography after Cardiac Arrest without ST-Segment Elevation

EtCO2

• End-tidal carbon dioxide monitoring and load band device for mechanical cardio-pulmonary resuscitation: Never trust the numbers, believe at the curves

Epinephrine

• The effects of adrenaline in out of hospital cardiac arrest with shockable and non-shockable rhythms: Findings from the PACA and PARAMEDIC-2 randomised controlled trials. Open Access

• #Epi: There is no place for the use of intravenous epinephrine as a standard component of cardiac arrest resuscitation care. Open Access

• Epinephrine during resuscitation of traumatic cardiac arrest and increased mortality: a post hoc analysis of prospective observational study. Open Access

• The Association of the Average Epinephrine Dosing Interval and Survival With Favorable Neurologic Status at Hospital Discharge in Out-of-Hospital Cardiac Arrest

Prehospital Critical Care

• The effect of prehospital critical care on survival following out-of-hospital cardiac arrest: A prospective observational study. Open Access

• Cost-effectiveness of advanced life support and prehospital critical care for out-of-hospital cardiac arrest in England: a decision analysis model. Open Access

Defibrillation

• Decreasing time to first shock: Routine application of defibrillation pads in prehospital STEMI

• Shorter defibrillation interval promotes successful defibrillation and resuscitation outcomes

• An investigation of inter-shock timing and electrode placement for double-sequential defibrillation

Extracorporeal Life Support

• Extracorporeal Life Support in the Emergency Department: A Narrative Review for the Emergency Physician

• Extracorporeal cardiopulmonary resuscitation for massive pulmonary embolism in a “hybrid emergency room”. Open Access

• Comparison of extracorporeal and conventional cardiopulmonary resuscitation: a retrospective propensity score matched study. Open Access

The rest

• Stress and decision-making in resuscitation: A systematic review. Open Access

• CaRdiac Arrest Survival Score (CRASS) — A tool to predict good neurological outcome after out-of-hospital cardiac arrest

• Prehospital determinants of successful resuscitation after traumatic and non-traumatic out-of-hospital cardiac arrest. Open Access

• Is point-of-care ultrasound a reliable predictor of outcome during atraumatic, non-shockable cardiac arrest? A systematic review and meta-analysis from the SHoC Investigators

• European Stroke Organisation (ESO) – European Society for Minimally Invasive Neurological Therapy (ESMINT) Guidelines on Mechanical Thrombectomy in Acute Ischemic Stroke

• 2019 Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology Guidelines on the Acute Management of ST-Elevation Myocardial Infarction: Focused Update on Regionalization and Reperfusion

• GINA. Global Initiative  for Asthma. 2019 Guidelines 

• Management of Pediatric Severe Traumatic Brain Injury: 2019 Consensus and Guidelines-Based Algorithm for First and Second Tier Therapies

• Evidence-Based Guidelines for EMS Administration of Naloxone

• Experts’ guidelines of intubation and extubation of the ICU patient of French Society of Anaesthesia and Intensive Care Medicine (SFAR) and French-speaking Intensive Care Society (SRLF)

• New clinical guidelines on the spinal stabilisation of adult trauma patients – consensus and evidence based

• Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke

• 2019 American Heart Association Focused Update on Advanced Cardiovascular Life Support: Use of Advanced Airways, Vasopressors, and Extracorporeal Cardiopulmonary Resuscitation During Cardiac Arrest

• 2019 ESC Guidelines for the management of patients with supraventricular tachycardia

• WSES consensus conference guidelines:monitoring and management of severe adult traumatic brain injury patients with polytrauma in the first 24 hours

• Wilderness Medical Society Clinical Practice Guidelines for Spinal Cord Protection

• Wilderness Medical Society Clinical Practice Guidelines for the Out-of-Hospital Evaluation and Treatment of Accidental Hypothermia: 2019 Update

• Wilderness Medical Society Clinical Practice Guidelines for the Prevention and Treatment of Heat Illness: 2019 Update

• Wilderness Medical Society Clinical Practice Guidelines for the Prevention and Treatment of Acute Altitude Illness: 2019 Update

• Wilderness Medical Society Clinical Practice Guidelines for the Prevention and Treatment of Frostbite: 2019 Update

• The 2019 ESC Guidelines on the Diagnosis and Management of Acute Pulmonary Embolism

• Difficult Airway Society guidelines for awake tracheal intubation (ATI) in adults

• Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America

• 2019 WSES guidelines for the management of severe acute pancreatitis

February

• Why are bleeding trauma patients still dying?. Open Access

March

• Potentially preventable trauma deaths: A retrospective review. Open Access

• Clearing the cervical spine in patients with distracting injuries: An AAST multi-institutional trial

May

• Effects of 20-degree spinal immobilization on respiratory functions in otherwise healthy volunteers with android-type obesity

June

• Prehospital prediction of severe injury in road traffic injuries: A multicenter cross-sectional study. Open Access

July

• Management of Burns

• Influence of prehospital physician presence on survival after severe trauma: Systematic review and meta-analysis

September

• Prehospital Protocols Reducing Long Spinal Board Use Are Not Associated with a Change in Incidence of Spinal Cord Injury

October

• Survival after pre-hospital emergency clamshell thoracotomy for blunt cardiac rupture. Open Access

• Prehospital Airway Management in Severe Traumatic Brain Injury

• Variation in the practice of tracheal intubation in Europe after traumatic brain injury: a prospective cohort study. Open Access

• Effects of tranexamic acid on death, disability, vascular occlusive events and other morbidities in patients with acute traumatic brain injury (CRASH-3): a randomised, placebo-controlled trial. Open Access

December

• A review of transfusion- and trauma-induced hypocalcemia. Is it time to change the lethal triad to the lethal diamond?

January

• The evaluation of a better intubation strategy when only the epiglottis is visible:a randomized, cross-over mannequin study

• Rapid sequence induction (RSI) in trauma patients: Insights from healthcare providers. Open access. 

February

• Shock Index as a Predictor of Post-Intubation Hypotension and Cardiac Arrest; A Review of the Current Evidence. Open Access

• Emergency Department Intubation Success With Succinylcholine Versus Rocuronium: A National Emergency Airway Registry Study. Open Access

• Will This Patient Be Difficult to Intubate? The Rational Clinical Examination Systematic Review

• Bag-Mask Ventilation during Tracheal Intubation of Critically Ill Adults

March

• Use of End Tidal Oxygen Monitoring to Assess Preoxygenation During Rapid Sequence Intubation in the Emergency Department

April

• Outcomes in video laryngoscopy studies from 2007 to 2017: systematic review and analysis of primary and secondary endpoints for a core set of outcomes in video laryngoscopy research. Open Access

May

• Effect of Pre-Hospital Intubation in Patients withSevere Traumatic Brain Injury on Outcome: A Prospective Cohort Study. Open Access

• The HEAVEN criteria predict laryngoscopic view and intubation success for both direct and video laryngoscopy: a cohort analysis. Open Access

• Requirement for urgent tracheal intubation after traumatic injury: a retrospective analysis of 11,010 patients in the Trauma Audit Research Network database

June

• Videolaryngoscopy in critically ill patients. Open Access

July

• Recent advances in laryngoscopy in adults. Open Access

August

• Percutaneous vs surgical emergency cricothyroidotomy: An experimental randomized crossover study on an animal‐larynx model. Open Access

September

• Intubation by Emergency Physicians: How Often Is Enough?

• Is the Mallampati Score Useful for Emergency Department Airway Management for Procedural Sedation?. Open Access

• Airway physical examination tests for detection of difficult airway management in apparently normal adult patients. Open Access

October

• Emergency front-of-neck airway: strategies for addressing its urgency

• Variation in the practice of tracheal intubation in Europe after traumatic brain injury: a prospective cohort study. Open Access

• Preoxygenation before intubation in adult patients with acute hypoxemic respiratory failure: a network meta-analysis of randomized trials. Open Access

• Effectiveness of Manual Ventilation in Intubated Helicopter Emergency Services−Transported Trauma Patients

November

• Effect of a fluid bolus on cardiovascular collapse among critically ill adults undergoing tracheal intubation (PrePARE): a randomised controlled trial

• The suction-assisted laryngoscopy assisted decontamination technique toward successful intubation during massive vomiting simulation. Open Access

December

• Effect of Rocuronium vs Succinylcholine on Endotracheal Intubation Success Rate Among Patients Undergoing Out-of-Hospital Rapid Sequence Intubation A Randomized Clinical Trial

For who has a multiyear experience in prehospital emergency medicine and deals everyday with emergency transportation of critical patients the sensation is that the use of emergency warning systems are, mostly of times, useless and doesn’t really have any impact on clinical outcomes. 

But beyond any subjective thought, do we have any evidence on that?

My analysis starts from this article published in 2018 on Annals of Emergency Medicine

by Brooke L. Watanabe, MD et al. and entitled  “Is Use of Warning Lights and Sirens Associated With Increased Risk of Ambulance Crashes? A Contemporary Analysis Using National EMS Information System (NEMSIS) Data”. The authors conclusion says that “Ambulance use of lights and sirens is associated with increased risk of ambulance crashes. The association is greatest during the transport phase. EMS providers should weigh these risks against any potential time savings associated with lights and sirens use.“

Curbside to Beside blog published an interesting post about this topic and resumed the data in this incredibly intuitive infographic

Data extrapolated from
Wantabe et al. (2018)

While ambulances crash rate when using L&S (light and sirens) in the response phase is slightly increased  (7.0 vs 5.4) in the transportation phase the amount of crashes associated with L&S use is significatively higher (17.1 vs 7.0). 

So L&S transportation increases the odd of crash (and this is intuitive) but, on the other side, is there any evidence that use of L&S increases response time and improve clinical outcome?

Fast is Time????

Fabrice Dami et al in an article entitled “Use of lights and siren: is there room for improvement?” found that the time saved with L&S transport was 1.75 min (105 s; P<0.001) in day time and 0.17 min (10.2 s; P=0.27) night-time.

So evidently fast is time, but is a gain of less than 2 min a clinical significative time?

Time is Life???

In 2010 in the article “Emergency Medical Services Intervals and Survival in Trauma:Assessment of the “Golden Hour” in a North AmericanProspective Cohort” concluded that “there was no association between EMS intervals and mortality among injured patients with physiologic abnormality in the field”.

Anderson et al in a 2014 article “Preventable deaths following emergency medical dispatch – an audit study” demonstrated how just 0,2% of the 94.488 “non L&S” dispatched emergencies died in the first 24 hours from the call.  Of those just 0.02% of total “non L&S” emergencies were considered “potentially preventable if the dispatcher had assessed the call as more urgent and this had led to an ambulance dispatch with a shorter response time and possible rendezvous with a physician-staffed mobile emergency care unit”

So mostly of the emergencies are not time sensitive and the clinical outcome does not differ if the transport time is shorter.

Take home messages for our system and for clinical practice

Maybe we need lights and sirens in response phase, cause slightly increase in accident risk corresponds to  some gain in arriving time on the scene.

Maybe we don’t need lights and sirens in transportation phase  cause a great increase in risk of crash do not correspond to a clinical sensitive time gain.

For sure when using L&S we need to be aware that the risk doesn’t worth the price, and even if we use L&S in the varies phases of emergencies pushing the threshold of                security too forward increases the risks and don’t improve clinical benefits for the transported patients.

Clinicians need to be more concerned about performing the right procedures to stabilise patients on pre-hospital phase more than hurrying  with unstable patients toward an unreal Eldorado and risking their own and patients lives. 

Non traumatic Transitory Lost Of Consciousness (TLOC) is a common cause of medical emergency call. Among TLOC Syncope is the most common cause. So the first challenge for an emergency professional is discerning from Syncope and non syncope situations (seizures, psychogenic, other rare causes).

2018 ESC Guidelines for the diagnosis and management of syncope

Syncope according to 2018 Guidelines definition is a “TLOC due to cerebral hypoperfusion, characterised by a rapid onset, short duration, and spontaneous complete recovery”. 

Among Syncope the causes can be found in vagal reflex (Reflex syncope), a drop in blood pressure due to a deficiency of compensation in a standing position (Orthostatic syncope) and a cardiac cause of syncope (Cardiac syncope)

2018 ESC Guidelines for the diagnosis and management of syncope

But what is the role and what can and must be done on the prehospital field to understand treat and risk stratify a Syncope?

Anamnesis

Is a fundamental step to understand and risk stratify a syncope episode. It has to be targeted to collect all the important informations and to don’t loose precious time.

We can divide the information we collect in two categories.

The first kind of information we area going to ask (to bystanders and patients) is about the syncope event.

• How much the lost of consciousness lasted
• How it happened (standing, sitting or laying)
• What was the patient doing (resting or during exercise)
• What the patient felt before the syncope (palpitations, chest pain, dyspnea, dizziness, other)
• What happened during or immediately after the syncope (seizures, other)

Second step is collecting informations about the patient medical conditions. We have to focus on

• What medical condition he actually suffers or suffered in the past
• Which kind of drugs he is actually doing

After a focus anamnesis the second step is about the physical exam of the patient.

Diagnostic tests

During physical exam a rapid general neurologic and cardiac examination has to be completed, but two additional steps need to be done in a syncope patients

• Orthostatic challenge in active standin position
• Carotid sinus massage (CSM) in patients aged >40 years.

Orthostatic challenge:  Standing BP evaluation has to be done after 3 minutes of active standing position with the patient fully monitored, and “abnormal BP fall is defined as a progressive and sustained fall in systolic BP from baseline value >_20 mmHg or diastolic BP >_10 mmHg, or a decrease in systolic BP to <90 mmHg” (European Society of Cardiology 2018 ESC Guidelines for the diagnosis and management of syncope).

Carotid sinus massage: A ventricular pause lasting >3 s and/or a fall in systolic BP of >50mmHg is known as carotid sinus hypersensitivity. “Carotid sinus syndrome (CSS) There is strong consensus that the diagnosis of CSS requires both the reproduction of spontaneous symptoms during CSM and clinical features of spontaneous syncope compatible with a reflex mechanism.” (European Society of Cardiology 2018 ESC Guidelines for the diagnosis and management of syncope)

12 leads EKG

It’s a fundamental diagnostic tool and has to be performed in all syncope patients.

What are the risky features we have to consider when looking to ann EKG of a syncope patients:

At least 6:

1. Ischemia
2. Arrithmia
3. Pre-excitation/WPW
4. Brugada pattern
5. Hypertrophic cardiomyopathy
6. Arrhythmogenic Right Ventricular Cardiomyopathy

POCUS

Is there a role for Point of Care Ultrasound in differential diagnosis and risk stratification of syncope.

Probably yes cause we can look at:

• Aorta for dissection
• VD/VS ratio for PE
• Pericardium for effusion
• EF for cardiac function evaluation

High risk VS non high risk syncope

At the end of those steps the prehospital professional has two chances.

1. There is a likely cause of syncope
2. The syncope is of unknown cause

2018 ESC Guidelines for the diagnosis and management of syncope

If the cause is known or very likely we have to follow the specific pathway.

In the unknown syncope we have to stratify the risk.

In prehospital field is important to look for high risk features of syncope:

• History of heart failure or other cardiac conditions
• Syncvope in supine position
• Syncope during excercise
• Dyspnea before or immediately following syncope
• Palpitations before syncope episode
• EKG abnormalities
• Persisting low blood pressure (SBP<90 mmHg) in supine positi
• Orthostatic Hypotension

Each one of those is indicative of high risk prehospital features and the patient need further ED examination.

In all other cases the clinician can decide case by case if the patient can be treated out of the hospital or need admission to ED.

References :

Michele Brignole, Angel Moya et al. European Society of Cardiology 2018 ESC Guidelines for the diagnosis and management of syncope