Pneumothorax remains an important cause of preventable trauma death. The aim of this systematic review is to synthesize the recent evidence on the efficacy, patient outcomes, and adverse events of different chest decompression approaches relevant to the out-of-hospital setting.

A comprehensive literature search was performed using five databases (from January 1, 2014 through June 15, 2020). To be considered eligible, studies required to report original data on decompression of suspected or proven traumatic pneumothorax and be considered relevant to the prehospital context. They also required to be conducted mostly on an adult population (expected more than ≥80% of the population ≥16 years old) of patients. Needle chest decompression (NCD), finger thoracostomy (FT), and tube thoracostomy were considered. No meta-analysis was performed. Level of evidence was assigned using the Harbour and Miller system.

A total of 1,420 citations were obtained by the search strategy, of which 20 studies were included. Overall, the level of evidence was low. Eleven studies reported on the efficacy and patient outcomes following chest decompression. The most studied technique was NCD (n = 7), followed by FT (n = 5). Definitions of a successful chest decompression were heterogeneous. Subjective improvement following NCD ranged between 18% and 86% (n = 6). Successful FT was reported for between 9.7% and 32.0% of interventions following a traumatic cardiac arrest. Adverse events were infrequently reported. Nine studies presented only on anatomical measures with predicted failure and success. The mean anterior chest wall thickness (CWT) was larger than the lateral CWT in all studies except one. The predicted success rate of NCD ranged between 90% and 100% when using needle >7cm (n = 7) both for the lateral and anterior approaches. The reported risk of iatrogenic injuries was higher for the lateral approach, mostly on the left side because of the proximity with the heart.

Based on observational studies with a low level of evidence, prehospital NCD should be performed using a needle >7cm length with either a lateral or anterior approach. While FT is an interesting diagnostic and therapeutic approach, evidence on the success rates and complications is limited. High-quality studies are required to determine the optimal chest decompression approach applicable in the out-of-hospital setting.

The threat of mass casualties caused by an unconventional terrorist attack is a challenge for the public health system, with special implications for emergency medicine, anesthesia, and intensive care. Advanced life support of patients injured by chemical or biological warfare agents requires an adequate level of personal protection. The aim of this study was to evaluate the personal protection knowledge of emergency physicians and anesthetists who would be at the frontline of the initial health response to a chemical/biological warfare agent incident.

After institutional review board approval, knowledge of personal protection measures among emergency medicine (n = 28) and anesthetics (n = 47) specialty registrars in the South Thames Region of the United Kingdom was surveyed using a standardized questionnaire. Participants were asked for the recommended level of personal protection if a chemical/biological warfare agent(s) casualty required advanced life support in the designated hospital resuscitation area.

The best awareness within both groups was regarding severe acute respiratory syndrome, and fair knowledge was found regarding anthrax, plague, Ebola, and smallpox. In both groups, knowledge about personal protection requirements against chemical warfare agents was limited. Knowledge about personal protection measures for biological agents was acceptable, but was limited for chemical warfare agents.

The results highlight the need to improve training and education regarding personal protection measures for medical first receivers.

Direct physician observation of advanced life support (ALS) personnel is rare in a demographically diverse state.

Twenty ALS agencies from throughout Arizona.

A board-certified emergency physician performed on-site interviews with the emergency medical services (EMS) supervisor of each agency to approximate the number of days per year that physicians observe ALS personnel in the field.

Only 11 agencies (55%) reported that physicians ever observed ALS personnel. Among all agencies, an estimated total of 84 observer-days occurred per year. The agencies staffed a total of 86 ALS units, resulting in an estimated 0.98 observer-days/unit/year (84/86). On the average, it took 3.4 ALS personnel to staff a given unit over time and the probability that an ALS provider would be on a unit on any given day was 0.29 (1/3.4). The probability of a given provider being observed during one year was approximately 0.29 (0.98 x 0.29). Thus, on the average, an ALS provider would be observed by a physician approximately once every 3.5 years (1/0.29). Among urban agencies, the “average” ALS provider would be observed once every 2.9 years. This compared to a likelihood of in-field observation of only once every 6.7 years for non-urban providers (p = .036).

The skills of ALS providers in Arizona are observed by a physician in the field very infrequently. Although an uncommon occurrence in urban agencies, observation of non-urban ALS personnel occurs even less frequently. In addition, nearly one-half of the agencies surveyed never had a physician-observer. Although a variety of skills evaluation methods exist, it remains unclear whether any method is as useful as direct observation. Future investigations are needed to evaluate whether in-field physician observation impacts skills, patient care, or outcome in EMS systems.

The purpose of this study was to evaluate the ability of first-year paramedic students to identify ST-segment elevation myocardial injury (STEMI) on 12-lead electrocardiograms (ECGs) following a three-hour presentation by a board-certified emergency medicine physician experienced in ECG interpretation.

Thirty-three first-year paramedic students with minimal to no experience in evaluating 12-lead ECGs were administered a pretest with 20 12-lead ECGs and were asked to evaluate each for: (1) presence of STEMI (STEMI identification); (2) if STEMI presents, ECG leads demonstrating ST-elevation (LEAD identification); and (3) if STEMI present, the anatomic distribution of the STEMI (ANATOMY identification). The students were randomized into two groups. Group 1 (16 students; control group) received a handout describing the evaluation of ECGs for STEMI, while Group 2 (17 students; experimental group) received the handout plus a threehour presentation on the evaluation of ECGs for STEMI. Following randomization, distribution of the STEMI handout and ECG STEMI presentation, a posttest with 20 new ECGs was administered to all participants. The pretest and posttest mean scores were compared between the two groups to determine if attendance at the presentation improved the paramedic students' abilities to evaluate and identify STEMI ECGs. Following the STEMI posttest, students in Group 1 were provided with the STEMI lecture. Students were retested with 20 new ECGs five months following the initial study to examine retention of the information taught.

The mean pre-test scores for the two groups (Group 1 vs Group 2, respectively) in STEMI identification (74.4 vs 75.6%; p = 0.79), lead identification (50.0 vs. 51.2%; p = 0.8) and anatomy identification (49.4 vs 51.8%; p = 0.60) were similar in all three categories. Post-test scores between Group 1 and Group 2 demonstrated statistically significant differences in STEMI identification (85.6 vs 92.4%; p <0.02), lead identification (73.4 vs 85.2%; p <0.02), and anatomy identification (65.9 vs 87.1%; p <0.01), with Group 2 demonstrating higher mean scores relative to Group 1 in all three categories. Comparison of mean initial pre-test and five-month retest scores for all students demonstrated statistically significant differences in STEMI identification (75.0 vs 87.4%; p <0.0001), lead identification (50.6 vs 82.2%; p <0.0001), and anatomy identification (50.6 vs 76.6%; p <0.0001).

The ability of first-year paramedic students to accurately detect STEMI on prehospital 12-lead ECGs is enhanced by a structured ECG STEMI presentation provided by an emergency medicine physician, and these students maintained excellent retention of STEMI ECG skills over a five-month period.

Children represent a vulnerable population, and special considerations are necessary to care for them properly during disasters. Comprehensive disaster responses include addressing the unique needs of children during mass-casualty incidents, such as the prevention of unintentional injuries. Early in the morning of 04 September 2005, approximately 1,600 Hurricane Katrina and/or flood survivors from NewOrleans, including approximately 300 children, arrived at Camp Gruber, an Oklahoma National Guard base in Eastern Oklahoma.

The primary function of Camp Gruber to train support personnel for the Oklahoma National Guard. This is not a child-safe environment. It was hypothesized that the camp contained numerous child injury hazards and that these hazards could be removed systematically using local child injury prevention experts, thereby preventing unintentional injuries to the displaced children.

On 08 September, “Operation Child-Safe” was launched by the Pediatric Injury Response Team to identify and remove pediatric injury hazards from Camp Gruber. Injury prevention experts from the Safe Kids Tulsa Area (SKTA) Chapter, the closest pediatric injury prevention group in the region, spearheaded the operation. Several visits were required to remove all of the injury hazards that were identified.

Many hazards were identified and removed immediately, while others were addressed in a formal letter to the Camp Gruber Commander for required consent to implement changes. Hazards identified in the camp included, but were not limited to: (1) dangerous chemicals; (2) choking hazards; (3) open electrical outlets; and (4) missing smoke detectors. Bicycle helmets, car seats, strollers, portable cribs, and other safety-related items were passed out to families in need. A licensed daycare facility also was established in order to give the adult guardians a break from constant supervision. Over the course of one month, only one preventable injury (minor head injury) was reported during camp operations, and this particular injury occurred two days before “Operation Child-Safe” was initiated (Day 3 of camp operations).

In the aftermath of an event that displaces large numbers of people, it is likely that children will be exposed to numerous injury hazards. Volunteers with expertise in child injury prevention are needed to make an evacuee shelter safer for children.

The staffing of ambulances with different levels of Emergency Medical Service (EMS) providers is a difficult decision with evidence being mixed on the benefit of each model.

The objective of this study was to describe a pilot program evaluating alternative staffing on two ambulances utilizing the paramedic-basic (PB) model (staffed with one paramedic and one emergency medical technician[EMT]).

This was a retrospective study conducted from September 17, 2013 through December 31, 2013. The PB ambulances were compared to geographically matched ambulances staffed with paramedic-paramedic (PP ambulances). One PP and one PB ambulance were based at Station A; one PP and one PB ambulance were based at Station B. The primary outcome was total on-scene time. Secondary outcomes included time-to-electrocardiogram (EKG), time-to-intravenous (IV) line insertion, IV-line success rate, and percentage of protocol violations. Inclusion criteria were all patients requesting prehospital services that were attended to by these teams. Patients were excluded if they were not attended to by the study ambulance vehicles. Descriptive statistics were reported as medians and interquartile ranges (IQR). Proportions were reported with 95% confidence intervals (CI). The Mann-Whitley U test was used for significance testing (P<.05).

Median on-scene times at Station A for the PP ambulance were shorter than the PB ambulance team (PP: 10.1 minutes, IQR 6.0-15; PB: 13.0 minutes, IQR 8.1-18; P=.01). This finding also was noted at Station B (PP: 13.5 minutes, IQR 8.5-19; PB: 14.3 minutes, IQR 9.9-20; P=.01). There were no differences between PP and PB ambulance teams at Station A or Station B in time-to-EKG, time-to-IV insertion, IV success rate, and protocol violation rates.

In the setting of a well-developed EMS system utilizing an all-Advanced Life Support (ALS) response, this study suggests that PB ambulance teams may function well when compared to PP ambulances. Though longer scene times were observed, differences in time to ALS interventions and protocol violation rates were not different. Hybrid ambulance teams may be an effective staffing alternative, but decisions to use this model must address clinical and operational concerns.

CortezEJ, PanchalAR, DavisJE, KesegDP. The Effect of Ambulance Staffing Models in a Metropolitan, Fire-Based EMS System. Prehosp Disaster Med. 2017;32(2):175–179.

Aortic dissection is difficult to detect in the early phase due to a variety of symptoms. This report describes the prehospital setting of aortic dissection in terms of symptoms, treatment, and suspicion by the Emergency Medical Service (EMS) staff.

All patients in the Municipality of Gothenburg, Sweden, who, in 2010 and 2011, had a hospital discharge diagnosis of aortic dissection (international classification of disease (ICD) I 71,0) were included. The exclusion criteria were: age < 18 years of age and having a planned operation. This was a retrospective, descriptive study based on patient records. In the statistical analyses, Fisher's exact test and the Mann-Whitney U test were used for analyses of dichotomous and continuous/ordered variables.

Of 92 patients, 78% were transported to the hospital by the EMS. The most common symptom was pain (94%). Pain was intensive or very intensive in 89% of patients, with no significant difference in relation to the use of the EMS. Only 47% of those using the EMS were given pain relief with narcotic analgesics. Only 12% were free from pain on admission to the hospital. A suspicion of aortic dissection was reported by the EMS staff in only 17% of cases. The most common preliminary diagnosis at the dispatch center (31%) and by EMS clinicians (52%) was chest pain or angina pectoris. In all, 79% of patients were discharged alive from the hospital (75% of those that used the EMS and 95% of those that did not).

Among patients who were hospitalized due to aortic dissection in Gothenburg, 78% used the EMS. Despite severe pain in the majority of patients, fewer than half received narcotic analgesics, and only 12% were free from pain on admission to the hospital. In fewer than one-in-five patients was a suspicion of aortic dissection reported by the EMS staff.

AxelssonC , KarlssonT , PandeK , WigertzK , ÖrtenwallP , NordanstigJ , HerlitzJ . A Description of the Prehospital Phase of Aortic Dissection in Terms of Early Suspicion and Treatment. Prehosp Disaster Med. 2015;30(2):1-8.

The objective is to identify research priorities in prehospital care in Spain.

This was a Delphi-type study of three rounds with a panel of experts made up of members of the Red de Investigación en Emergencias Prehospitalarias (RINVEMER; Prehospital Emergency Research Network) Network and the Sociedad Española de Medicina de Urgencias y Emergencias (SEMES; Spanish Society of Emergency Medicine) Emergency Secretariat. In the first round, each participant identified up to 15 priorities. In the second round, they scored the 30 thematic areas on a Likert scale. In the third round, they ordered and scored from one to ten the first ten priorities among those that obtained a median greater than or equal to four in the second round. After adding the assigned scores, the ten priorities with the highest total score were obtained.

The ten identified research priorities were: special clinical codes and time-dependent conditions; mass-casualty incident (MCI) coordination and management; innovation in Emergency Medical Services (EMS); human factor in decision making; triage, analysis, and management of calls in the Emergency Call Center; new technologies, telemedicine, and emergencies; adverse events, clinical safety, and quality in emergencies; cardiac arrest; continuous education and training (methodology, quality, and evaluation); and big data and emergencies.

The research priorities perceived by emergency professionals are related to clinical care and organizational aspects of EMS, in addition to the need to incorporate innovative aspects and new data analysis technologies.