Opioid use disorder is a cause of significant morbidity and mortality. In order to reverse opioid overdose as quickly as possible, many institutions and municipalities have encouraged people with no professional medical training to carry and administer naloxone. This study sought to provide preliminary data for research into the rates of adverse effects of naloxone when administered by bystanders compared to Emergency Medical Services (EMS) personnel, since this question has not been studied previously.

This was a retrospective cohort study performed at an urban, tertiary, academic medical center that operates its own EMS service. A consecutive sample of patients presenting to EMS with opioid overdose requiring naloxone was separated into two groups based on whether naloxone was administered by bystanders or by EMS personnel. Each group was analyzed to determine the incidence of four pre-specified adverse events.

There was no significant difference in the rate of adverse events between the bystander (19%) and EMS (16%) groups (OR = 1.23; 95% CI, 0.63 - 2.32; P = .499) in this small sample. Based on these initial results, a study would need a sample size of 6,188 in order to reach this conclusion with 80% power. Similarly, there were no significant differences in the rates of any of the individual adverse events. Secondary analysis of patients’ demographics showed differences between the two groups which generate hypotheses for further investigation of disparities in naloxone administration.

This preliminary study provides foundational data for further investigation of naloxone administration by bystanders. Adverse events after the prehospital administration of naloxone are rare, and future studies will require large sample sizes. These preliminary data did not demonstrate a statistically significant difference in adverse event rates when comparing naloxone administration by bystanders and EMS clinicians. This study provides data that will be useful for conducting further research on multiple facets of this topic.

Cricothyroidotomy is an advanced airway procedure for critically ill or injured patients. In Victoria, Australia, intensive care paramedics (ICPs) perform needle cricothyroidotomy utilizing the proprietary QuickTrach II (QTII) device. Recently, an Ambulance Victoria (AV) institutional change in workflow included pre-puncture surgical incision to assist in successful placement. This review aims to explore whether a surgical pre-incision prior to the insertion of the device improved overall procedural success rates of needle cricothyroidotomy using the QTII.

This was a retrospective review of all patients who received a needle cricothyroidotomy by ICPs from May 1, 2015 through September 15, 2020. Data and patient care records were sourced from the AV data warehouse.

A total of 27 patients underwent a needle cricothyroidotomy with the mean age of patients being 50.2 years. Most cricothyroidotomies were performed using the QuickTrach II kit (92.6%). Prior to modification of the QTII procedure, front-of-neck access (FONA) success was 50.0%; however, this improved to 82.4% after the procedures recent update. The overall success rate of all paramedic-performed needle cricothyroidotomy during the study period was 74.1% (n = 20).

This review demonstrates that propriety devices such as the QTII device achieve a low success rate for a FONA intervention. Despite the low frequency of this procedure, ICPs with extensive training and regular maintenance can perform needle cricothyroidotomy using scalpel assistance with a reasonable success rate. But when compared to the broader literature, success rate using a more straightforward technique such as a surgical cricothyroidotomy technique is likely going to be higher.

Many triage algorithms exist for use in mass-casualty incidents (MCIs) involving pediatric patients. Most of these algorithms have not been validated for reliability across users.

Investigators sought to compare inter-rater reliability (IRR) and agreement among five MCI algorithms used in the pediatric population.

A dataset of 253 pediatric (<14 years of age) trauma activations from a Level I trauma center was used to obtain prehospital information and demographics. Three raters were trained on five MCI triage algorithms: Simple Triage and Rapid Treatment (START) and JumpSTART, as appropriate for age (combined as J-START); Sort Assess Life-Saving Intervention Treatment (SALT); Pediatric Triage Tape (PTT); CareFlight (CF); and Sacco Triage Method (STM). Patient outcomes were collected but not available to raters. Each rater triaged the full set of patients into Green, Yellow, Red, or Black categories with each of the five MCI algorithms. The IRR was reported as weighted kappa scores with 95% confidence intervals (CI). Descriptive statistics were used to describe inter-rater and inter-MCI algorithm agreement.

Of the 253 patients, 247 had complete triage assignments among the five algorithms and were included in the study. The IRR was excellent for a majority of the algorithms; however, J-START and CF had the highest reliability with a kappa 0.94 or higher (0.9-1.0, 95% CI for overall weighted kappa). The greatest variability was in SALT among Green and Yellow patients. Overall, J-START and CF had the highest inter-rater and inter-MCI algorithm agreements.

The IRR was excellent for a majority of the algorithms. The SALT algorithm, which contains subjective components, had the lowest IRR when applied to this dataset of pediatric trauma patients. Both J-START and CF demonstrated the best overall reliability and agreement.

Prehospital intramuscular (IM) ketamine is increasingly used for chemical restraint of agitated patients. However, few studies have assessed emergency department (ED) follow-up of patients receiving prehospital ketamine for this indication, with previous reports suggesting a high rate of post-administration intubation. This study examines the rate of and reasons for intubation and other airway interventions in agitated patients who received ketamine by Emergency Medical Services (EMS).

This retrospective cohort study included patients who received prehospital ketamine for agitation and were transported to two community hospital EDs. Charts were reviewed for demographics, ketamine dose, and airway intervention by EMS or in the ED. Characteristics of patients who were intubated versus those who did not receive airway intervention were analyzed.

Over 28 months, 86 patients received ketamine for agitation. Fourteen (16.3%) underwent endotracheal intubation. Patients with a higher temperature and a lower Glasgow Coma Score (GCS) were more likely to require intubation. There was no age or dose-dependent association on intubation rate. Intubated patients averaged 39 years old versus 44 for patients not intubated (negative five-year difference; 95% CI, -16 to 6). The mean ketamine dose was 339.3mg in patients intubated versus 350.7mg in patients not (-11.4mg difference; 95% CI, -72.4 to 49.6). The mean weight-based ketamine dose was 4.44mg/kg in patients intubated versus 4.96mg/kg in patients not (-0.53mg/kg difference; 95% CI, -1.49 to 0.43).

The observed rate of intubation in patients receiving prehospital ketamine for agitation was 16.3%. Study data did not reveal an age or dose-dependent rate of intubation. Further research should be conducted to compare the airway intervention rate of agitated patients receiving ketamine versus other sedatives in a controlled fashion.

Traumatic brain injuries (TBIs) are an important cause of mortality and disability around the world. Early intervention and stabilization are necessary to obtain optimal outcomes, yet little is written on the topic in low- and middle-income countries (LMICs). The aim is to provide a descriptive analysis of patients with TBI treated by Service d’Aide Medicale Urgente (SAMU), the prehospital ambulance service in Kigali, Rwanda.

What is the incidence and nature of TBI seen on the ambulance in Kigali, Rwanda?

A retrospective descriptive analysis was performed using SAMU records captured on an electronic database from December 2012 through May 2016. Variables included demographic information, injury characteristics, and interventional data.

Patients with TBIs accounted for 18.0% (n = 2,012) of all SAMU cases. The incidence of TBIs in Kigali was 234 crashes per 100,000 people. The mean age was 30.5 (SD = 11.5) years and 81.5% (n = 1,615) were men. The most common mechanisms were road traffic incidents (RTIs; 78.5%, n = 1,535), assault (10.7%, n=216), and falls (7.8%, n=156). Most patients experienced mild TBI (Glasgow Coma Score [GCS] ≥ 13; 83.5%, n = 1,625). The most common interventions were provision of pain medications (71.0%, n = 1,429), placement of a cervical collar (53.6%, n = 1,079), and administration of intravenous fluids (48.7%, n = 979). In total, TBIs were involved in 67.0% of all mortalities seen by SAMU.

Currently, TBIs represent a large burden of disease managed in the prehospital setting of Kigali, Rwanda. These injuries are most often caused by RTIs and were observed in 67% of mortalities seen by SAMU. Rwanda has implemented several initiatives to reduce the incidence of TBIs with a specific emphasis on road safety. Further efforts are needed to better prevent these injuries. Countries seeking to develop prehospital care capacity should train providers to manage patients with TBIs.

Serotonin and sympathomimetic toxicity (SST) after ingestion of amphetamine-based drugs can lead to severe morbidity and death. There have been evaluations of the safety and efficacy of on-site treatment protocols for SST at music festivals.

The study aimed to examine the safety and efficacy of treating patients with SST on-site at a music festival using a protocol adapted from hospital-based treatment of SST.

The study is an audit of presentations with SST over a one-year period. The primary outcome was need for ambulance transport to hospital. The threshold for safety was prospectively defined as less than 10% of patients requiring ambulance transport to hospital.

The protocol suggested patients be treated with a combination of benzodiazepines; cold intravenous (IV) fluid; specific therapies (cyproheptadine, chlorpromazine, and clonidine); rapid sequence intubation; and cooling with ice, misted water, and convection techniques.

One patient of 13 (7.7%) patients with mild or moderate SST required ambulance transport to hospital. Two of seven further patients with severe SST required transport to hospital.

On-site treatment may be a safe, efficacious, and efficient alternative to urgent transport to hospital for patients with mild and moderate SST. The keys to success of the protocol tested included inclusive and clear education of staff at all levels of the organization, robust referral pathways to senior clinical staff, and the rapid delivery of therapies aimed at rapidly lowering body temperature. Further collaborative research is required to define the optimal approach to patients with SST at music festivals.

Air medical transport of trauma patients from the scene of injury plays a critical role in the delivery of severely injured patients to trauma centers. Over-triage of patients to trauma centers reduces the system efficiency and jeopardizes safety of air medical crews.

The objective of this study was to determine which triage factors utilized by Emergency Medical Services (EMS) providers are strong predictors of early discharge for trauma patients transported by helicopter to a trauma center.

A retrospective chart review over a two-year period was performed for trauma patients flown from the injury site into a Level I trauma center by an air medical transport program. Demographic and clinical data were collected on each patient. Prehospital factors such as Glasgow Coma Score (GCS), Revised Trauma Score (RTS), intubation status, mechanism of injury, anatomic injuries, physiologic parameters, and any combinations of these factors were investigated to determine which triage criteria accurately predicted early discharge. Hospital factors such as Injury Severity Score (ISS), length-of-stay (LOS), survival, and emergency department disposition were also collected. Early discharge was defined as a hospital stay of less than 24 hours in a patient who survives their injuries. A more stringent definition of appropriate triage was defined as a patient with in-hospital death, an ISS >15, those taken to the operating room (OR) or intensive care unit (ICU), or those receiving blood products. Those patients who failed to meet these criteria were also used to determine over-triage rates.

An overall early discharge rate of 35% was found among the study population. Furthermore, when the more stringent definition was applied, over-triage rates were as high as 85%. Positive predictive values indicated that patients who met at least one anatomic and physiologic criteria were appropriately transported by helicopter as 94% of these patients had stays longer than 24 hours. No other criteria or combination of criteria had a high predictive value for early discharge.

No individual triage criteria or combination of criteria examined demonstrated the ability to uniformly predict an early discharge. Although helicopter transport and subsequent hospital care is costly and resource consuming, it appears that a significant number of patients will be discharged within 24 hours of their transport to a trauma center. Future studies must determine the impact of eliminating “low-yield” triage criteria on under-triage of scene trauma patients.

Terror attacks have increased in frequency, and tactics utilized have evolved. This creates significant challenges for first responders providing life-saving medical care in their immediate aftermath. The use of coordinated and multi-site attack modalities exacerbates these challenges. The use of triage is not well-validated in mass-casualty settings, and in the setting of intentional mass violence, new and innovative approaches are needed.

Literature sourced from gray and peer-reviewed sources was used to perform a comparative analysis on the application of triage during the 2011 Oslo/Utoya Island (Norway), 2015 Paris (France), and 2015 San Bernardino (California USA) terrorist attacks. A thematic narrative identifies strengths and weaknesses of current triage systems in the setting of complex, coordinated terrorist attacks (CCTAs).

Triage systems were either not utilized, not available, or adapted and improvised to the tactical setting. The complexity of working with large numbers of patients, sensory deprived environments, high physiological stress, and dynamic threat profiles created significant barriers to the implementation of triage systems designed around flow charts, physiological variables, and the use of tags. Issues were identified around patient movement and “tactical triage.”

Current triage tools are inadequate for use in insecure environments, such as the response to CCTAs. Further research and validation are required for novel approaches that simplify tactical triage and support its effective application. Simple solutions exist in tactical triage, patient movement, and tag use, and should be considered as part of an overall triage system.

Triaging plays an important role in providing suitable care to a large number of casualties in a disaster setting. A Pediatric Physiological and Anatomical Triage Score (PPATS) was developed as a new secondary triage method. This study aimed to validate the accuracy of the PPATS in identifying injured pediatric patients who are admitted at a high frequency and require immediate treatment in a disaster setting. The PPATS method was also compared with the current triage methods, such as the Triage Revised Trauma Score (TRTS).

A retrospective review of pediatric patients aged ≤15 years, registered in the Japan Trauma Data Bank (JTDB) from 2012 through 2016, was conducted and PPATS was performed. The PPATS method graded patients from zero to 22, and was calculated based on vital signs, anatomical abnormalities, and the need for life-saving interventions. It categorized patients based on their priority, and the intensive care unit (ICU)-indicated patients were assigned a PPATS ≥six. The accuracy of PPATS and TRTS in predicting the outcome of ICU-indicated patients was compared.

Of 2,005 pediatric patients, 1,002 (50%) were admitted to the ICU. The median age of the patients was nine years (interquartile range [IQR]: 6-13 years). The sensitivity and specificity of PPATS were 78.6% and 43.7%, respectively. The area under the receiver-operating characteristic (ROC) curve (AUC) was larger for PPATS (0.61; 95% confidence interval [CI], 0.59-0.63) than for TRTS (0.57; 95% CI, 0.56-0.59; P <.01). Regression analysis showed a significant correlation between PPATS and the Injury Severity Score (ISS; r2 = 0.353; P <.001), predicted survival rate (r2 = 0.396; P <.001), and duration of hospital stay (r2 = 0.252; P <.001).

The accuracy of PPATS for injured pediatric patients was superior to that of current secondary triage methods. The PPATS method is useful not only for identifying high-priority patients, but also for determining the priority ranking for medical treatments and evacuation.

Triage has an important role in providing suitable care to the largest number of casualties in a disaster setting, but there are no secondary triage methods suitable for children. This study developed a new secondary triage method named the Pediatric Physiological and Anatomical Triage Score (PPATS) and compared its accuracy with current triage methods.

A retrospective chart review of pediatric patients under 16 years old transferred to an emergency center from 2014 to 2016 was performed. The PPATS categorized the patients, defined the intensive care unit (ICU)-indicated patients if the category was highest, and compared the accuracy of prediction of ICU-indicated patients among PPATS, Physiological and Anatomical Triage (PAT), and Triage Revised Trauma Score (TRTS).

Among 137 patients, 24 (17.5%) were admitted to ICU. The median PPATS score of these patients was significantly higher than that of patients not admitted to ICU (11 [IQR: 9-13] versus three [IQR: 2-4]; P<.001). The optimal cut-off value of the PPTAS was six, yielding a sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of 95.8%, 86.7%, 60.5%, and 99.0%. The area under the receiver-operating characteristic curve (AUC) was larger for PPTAS than for PAT or TRTS (0.95 [95% CI, 0.87-1.00] versus 0.65 [95% CI, 0.58-0.72]; P<.001 and 0.79 [95% CI, 0.69-0.89]; P=.003, respectively). Regression analysis showed a significant association between the PPATS and the predicted mortality rate (r2=0.139; P<.001), ventilation time (r2=0.320; P<.001), ICU stay (r2=0.362; P<.001), and hospital stay (r2=0.308; P<.001).

The accuracy of PPATS was superior to other methods for secondary triage of children.

ToidaC, MugurumaT, AbeT, ShinoharaM, GakumazawaM, YogoN, ShirasawaA, MorimuraN. Introduction of Pediatric Physiological and Anatomical Triage Score in Mass-Casualty Incident. Prehosp Disaster Med. 2018;33(2):147–152.

Prehospital ultrasound (PHUS) assessments by physicians and non-physicians are performed on medical and trauma patients with increasing frequency. Prehospital ultrasound has been shown to be of benefit by supporting interventions.

Which patients may benefit from PHUS has not been clearly identified.

A multi-variable logistic regression analysis was performed on a previously created retrospective dataset of five years of physician- and non-physician-performed ultrasound scans in a Canadian critical care Helicopter Emergency Medical Service (HEMS). For separate medical and trauma patient groups, the a-priori outcome assessed was patient characteristics associated with the outcome variable of “PHUS-supported intervention.”

Both models were assessed (Likelihood Ratio, Score, and Wald) as a good fit. For medical patients, the characteristics of heart rate (HR) and shock index (SI) were found to be most significant for an intervention being supported by PHUS. An extremely low HR was found to be the most significant (OR=15.86 [95% confidence interval (CI), 1.46-171.73]; P=.02). The higher the SI, the more likely that an intervention was supported by PHUS (SI 0.9 to<1.3: OR=9.15 [95% CI, 1.36-61.69]; P=.02; and SI 1.3+: OR=8.37 [95% CI, 0.69-101.66]; P=.09). For trauma patients, the characteristics of Prehospital Index (PHI) and SI were found to be most significant for PHUS support. The greatest effect was PHI, where increasing ORs were seen with increasing PHI (PHI 14-19: OR=13.36 [95% CI, 1.92-92.81]; P=.008; and PHI 20-24: OR=53.10 [95% CI, 4.83-583.86]; P=.001). Shock index was found to be similar, though, with lower impact and significance (SI 0.9 to<1.3: OR=9.11 [95% CI, 1.31-63.32]; P=.025; and SI 1.3+: OR=35.75 [95% CI, 2.51-509.81]; P=.008).

In a critical care HEMS, markers of higher patient acuity in both medical and trauma patients were associated with occurrences when an intervention was supported by PHUS. Prospective study with in-hospital follow-up is required to confirm these hypothesis-generating results.

O’DochartaighD, DoumaM, AlexiuC, RyanS, MacKenzieM. Utilization Criteria for Prehospital Ultrasound in a Canadian Critical Care Helicopter Emergency Medical Service: Determining Who Might Benefit. Prehosp Disaster Med. 2017;32(5):536–540.

Early identification of traumatic brain injury (TBI) is essential. Near-infrared spectroscopy (NIRS) can be used in prehospital settings for non-invasive monitoring and the diagnosis of patients who may require surgical intervention.

The handheld NIRS Infrascanner (InfraScan Inc.; Philadelphia, Pennsylvania USA) uses eight symmetrical scan points to detect intracranial bleeding. A scanner was tested in a physician-staffed helicopter Emergency Medical Service (HEMS). The results were compared with those obtained using in-hospital computed tomography (CT) scans. Scan time, ease-of-use, and change in treatment were scored.

A total of 25 patients were included. Complete scans were performed in 60% of patients. In 15 patients, the scan was abnormal, and in one patient, the scan resulted in a treatment change. Compared with the results of CT scanning, the Infrascanner obtained a sensitivity of 93.3% and a specificity of 78.6%. Most patients had severe TBI with indication for transport to a trauma center prior to scanning. In one patient, the scan resulted in a treatment change. Evaluation of patients with less severe TBI is needed to support the usefulness of the Infrascanner as a prehospital triage tool.

Promising results were obtained using the InfraScan NIRS device in prehospital screening for intracranial hematomas in TBI patients. High sensitivity and good specificity were found. Further research is necessary to determine the beneficial effects of enhanced prehospital screening on triage, survival, and quality of life in TBI patients.

PetersJ, Van WageningenB, HoogerwerfN, TanE. Near-Infrared Spectroscopy: A Promising Prehospital Tool for Management of Traumatic Brain Injury. Prehosp Disaster Med. 2017;32(4):414–418.

Injury is responsible for nearly five million annual deaths worldwide, and nearly 90% of these deaths occur in low- and middle-income countries (LMICs). Reliable clinical data detailing the epidemiology of injury are necessary for improved care delivery, but they are lacking in these regions.

A retrospective review of the Service d’Aide Medicale Urgente (SAMU; Kigali, Rwanda) prehospital database for patients with traumatic injury-related conditions from December 2012 through November 2014 was conducted. Chi-squared analysis, binomial probability test, and student’s t-test were used, where appropriate, to describe patient demographics, injury patterns, and temporal and geographic trends of injuries.

In the two-year period, 3,357 patients were managed by SAMU for traumatic injuries. Males were 76.5% of the study population, and the median age of all injured patients was 29 years (IQR=23-35). The most common causes of injury were road traffic crashes (RTCs; 73.4%), stabbings/cuts (11.1%), and falls (9.4%), and the most common anatomic regions injured were the head (55.7%), lower (45.0%) extremities, and upper (27.0%) extremities. Almost one-fourth of injured patients suffered a fracture (24.9%). The most common mechanism of injury for adults was motorcycle-related RTCs (61.4%), whereas children were more commonly injured as pedestrians (59.8%). Centrally located sectors within Kigali represented common areas for RTCs.

These data support the call for focused injury prevention strategies, some of which already are underway in Rwanda. Further research on care processes and clinical outcomes for injured patients may help identify avenues for improved care delivery.

EnumahS, ScottJW, MaineR, UwitonzeE, NyinawankusiJD, RivielloR, ByiringiroJC, KabagemaI, JayaramanS. Rwanda’s Model Prehospital Emergency Care Service: A Two-year Review of Patient Demographics and Injury Patterns in Kigali. Prehosp Disaster Med. 2016;31(6):614–620.

On-scene time (OST) previously has been shown to be a significant component of Emergency Medical Services’ (EMS’) operational delay in acute stroke. Since stroke patients are managed routinely by two-person ambulance crews, increasing the number of personnel available on the scene is a possible method to improve their performance.

Using fire engine crews to support ambulances on the scene in acute stroke is hypothesized to be associated with a shorter OST.

All patients transported to hospital as thrombolysis candidates during a one-year study period were registered by the ambulance crews using a case report form that included patient characteristics and operational EMS data.

Seventy-seven patients (41 [53%] male; mean age of 68.9 years [SD=15]; mean Glasgow Coma Score [GCS] of 15 points [IQR=14-15]) were eligible for the study. Forty-five cases were managed by ambulance and fire engine crews together and 32 by the ambulance crews alone. The median ambulance response time was seven minutes (IQR=5-10) and the fire engine response time was six minutes (IQR=5-8). The number of EMS personnel on the scene was six (IQR=5-7) and two (IQR=2-2), and the OST was 21 minutes (IQR=18-26) and 24 minutes (IQR=20-32; P =.073) for the groups, respectively. In a following regression analysis, using stroke as the dispatch code was the only variable associated with short (<22 minutes) OST with an odds ratio of 3.952 (95% CI, 1.279-12.207).

Dispatching fire engine crews to support ambulances in acute stroke care was not associated with a shorter on-scene stay when compared to standard management by two-person ambulance crews alone. Using stroke as the dispatch code was the only variable that was associated independently with a short OST.

PuolakkaT , VäyrynenT , ErkkiläE-P , KuismaM . Fire Engine Support and On-scene Time in Prehospital Stroke Care – A Prospective Observational Study. Prehosp Disaster Med. 2016;31(3):278–281.

Using the Medical Priority Dispatch System (MPDS) – a systematic 911 triage process – to identify a large subset of low-acuity patients for secondary nurse triage in the 911 center is a largely unstudied practice in North America. This study examines the ALPHA-level subset of low-acuity patients in the MPDS to determine the suitability of these patients for secondary triage by evaluating vital signs and necessity of lights-and-siren transport, as determined by attending Emergency Medical Services (EMS) ambulance crews.

The primary objective of this study was to determine the clinical status of MPDS ALPHA-level (low-acuity) patients, as determined by on-scene EMS crews’ patient care records, in two US agencies. A secondary objective was to determine which ALPHA-level codes are suitable candidates for secondary triage by a trained Emergency Communication Nurse (ECN).

In this retrospective study, one full year (2013) of both dispatch data and EMS patient records data, associated with all calls coded at the ALPHA-level (low-acuity) in the dispatch protocol, were collected. The primary outcome measure was the number and percentage of ALPHA-level codes categorized as low-acuity, moderate-acuity, high-acuity, and critical using four common vital signs to assign these categories: systolic blood pressure (SBP), pulse rate (PR), oxygen saturation (SpO2), and Glasgow Coma Score (GCS). Vital sign data were obtained from ambulance crew electronic patient care records (ePCRs). The secondary endpoint was the number and percentage of ALPHA-level codes that received a “hot” (lights-and-siren) transport.

Out of 19,300 cases, 16,763 (86.9%) were included in the final analysis, after excluding cases from health care providers and those with missing data. Of those, 89% of all cases did not have even one vital sign indicator of unstable patient status (high or critical vital sign). Of all cases, only 1.1% were transported lights-and-siren.

With the exception of the low-acuity, ALPHA-level seizure cases, the ALPHA-level patients are suitable to transfer for secondary triage in a best-practices, accredited, emergency medical dispatch center that utilizes the MPDS at very high compliance rates. The secondary nurse triage process should identify the few at-risk patients that exist in the low-acuity calls.

ScottG , ClawsonJ , FivazMC , McQueenJ , GardettMI , SchultzB , YoungquistS , OlolaCHO . Using On-scene EMS Responders’ Assessment and Electronic Patient Care Records to Evaluate the Suitability of EMD-triaged, Low-acuity Calls for Secondary Nurse Triage in 911 Centers. Prehosp Disaster Med. 2016;31(1):46–57.

The Glasgow Coma Scale (GCS) is widely applied in the emergency setting; it is used to guide trauma triage and for the application of essential interventions such as endotracheal intubation. However, inter-rater reliability of GCS scoring has been shown to be low for inexperienced users, especially for the motor component. Concerns regarding the accuracy and validity of GCS scoring between various types of emergency care providers have been expressed.

The objective of this study was to determine the degree of accuracy of GCS scoring between various emergency care providers within a modern Emergency Medical Services (EMS) system.

This was a prospective observational study of the accuracy of GCS scoring using a convenience sample of various types of emergency medical providers using standardized video vignettes. Ten video vignettes using adults were prepared and scored by two board-certified neurologists. Inter-rater reliability was excellent (Cohen's κ = 1). Subjects viewed the video and then scored each scenario. The scoring of subjects was compared to expert scoring of the two board-certified neurologists.

A total of 217 emergency providers watched 10 video vignettes and provided 2,084 observations of GCS scoring. Overall total GCS scoring accuracy was 33.1% (95% CI, 30.2-36.0). The highest accuracy was observed on the verbal component of the GCS (69.2%; 95% CI, 67.8-70.4). The eye-opening component was the second most accurate (61.2%; 95% CI, 59.5-62.9). The least accurate component was the motor component (59.8%; 95% CI, 58.1-61.5). A small number of subjects (9.2%) assigned GCS scores that do not exist in the GCS scoring system.

Glasgow Coma Scale scoring should not be considered accurate. A more simplified scoring system should be developed and validated.

BledsoeBE, CaseyMJ, FeldmanJ, JohnsonL, DielS, ForredW, GormanC. Glasgow Coma Scale Scoring is Often Inaccurate. Prehosp Disaster Med. 2015;30(1):1-8.

The aim of this study was to determine the effect of prehospital time and advanced trauma life support interventions for trauma patients transported to an Iranian Trauma Center.

This study was a retrospective study of trauma victims presenting to a trauma center in central Iran by Emergency Medical Services (EMS) and hospitalized more than 24 hours. Demographic and injury characteristics were obtained, including accident location, damaged organs, injury mechanism, injury severity score, prehospital times (response, scene, and transport), interventions and in-hospital outcome.

Two thousand patients were studied with an average age of 36.3 (SD = 20.8) years; 83.1% were male. One hundred twenty patients (6.1%) died during hospitalization. The mean response time, at scene time and transport time were 6.6 (SD = 3), 11.1 (SD = 5.2) and 12.8 (SD = 9.4), respectively. There was a significant association of longer transport time to worse outcome (P = .02). There was a trend for patients with transport times >10 minutes to die (OR: 0.8; 95% CI, 0.1-6.59). Advanced Life Support (ALS) interventions were applied for patients with severe injuries (Revised Trauma Score ⩽7) and ALS intervention was associated with more time on scene. There was a positive association of survival with ALS interventions applied in suburban areas (P = .001).

In-hospital trauma mortality was more common for patients with severe injuries and long prehospital transport times. While more severely injured patients received ALS interventions and died, these interventions were associated with positive survival trends when conducted in suburban and out-of-city road locations with long transport times.

HosseinpourM, ParavarM, MohammadzadehM, MirzadehAS. Prehospital Care and In-hospital Mortality of Trauma Patients in Iran. Prehosp Disaster Med. 2014;29(5):1-5.