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Objectives: Airway management is a fundamental skill that Emergency Medical Services (EMS) clinicians must be prepared to perform on patients of any age. We performed one of the first epidemiological studies of out-of-hospital pediatric airway management utilizing the ESO data set., Methods: We used the 2019 ESO Data Collaborative public release research data set. We performed a descriptive analysis of all patients <18 years receiving at least one of the following airway management interventions: nasopharyngeal airway, oropharyngeal airway, noninvasive positive pressure ventilation (NIPPV), airway suctioning, bag-valve-mask ventilation (BVM), tracheal intubation (TI), supraglottic airway (SGA) or surgical airway placement. We determined the success rates for BVM, TI and SGA., Results: Among 7,422,710 911 EMS activations, there were 346,912 pediatric encounters that resulted in patient care. Airway management occurred in 27,071 encounters (7,803 per 100,000 pediatric EMS patient care events). Use of BVM, intubation or supraglottic airway insertion occurred in 3,496 encounters (1,007 per 100,000 pediatric EMS patient care events). Ventilation with BVM occurred in 2,226 encounters (642 per 100,000 pediatric EMS patient care events), TI in 935 pediatric EMS patient care encounters (270 per 100,000 patient care encounters), and supraglottic airway insertion in 335 patient encounters (97 per 100,000 patient care encounters). Overall TI success was 71.4%, rapid sequence intubation success was 86.3%, and SGA success was 87.2%. Overall TI first pass success rate was 63.1%., Conclusions: In the ESO cohort, advanced airway management of children occurred in only 5.9 in 10,000 911 emergency encounters. Overall and first pass success rates for TI were low. These data provide contemporary perspectives of pediatric prehospital airway management in the United States.

Background: Injurious falls represent a significant public health burden. Research and policies have primarily focused on falls occurring indoors despite evidence that outdoor falls account for 47-58% of all falls requiring some medical attention. This study described the clinical trauma severity of indoor versus outdoor injurious falls requiring Emergency Medical Services (EMS) response., Methods: Using the 2019 National Emergency Medical Services Information System (NEMSIS) dataset, we identified the location of patients injured from falls that required EMS response. We classified injury severity using (1) the Revised Trauma Score for Triage (T-RTS): ≤ 11 indicated the need for transport to a Trauma Center; (2) Glasgow Coma Scale (GCS): ≤ 8 and 9-12 indicated severe and moderate neurologic injury; and (3) patient clinical acuity by EMS: Dead, Critical, Emergent, Low., Results: Of 1,854,909 encounters for patients with injurious falls, the vast majority occurred indoors (n = 1,596,860) compared to outdoors (n = 152,994). For patients who fell indoors vs outdoors on streets or sidewalks, the proportions were comparable for moderate or severe GCS scores (3.0% vs 3.9%), T-RTS scores indicating need for transport to a Trauma Center (5.2% vs 5.9%) and EMS acuity rated as Emergent or Critical (27.7% vs 27.1%). Injurious falls were more severe among male patients compared to females and males injured by falling on streets or sidewalks had higher percentages for moderate or severe GCS scores (5.2% vs 1.9%) and T-RTS scores indicating the need for transport to a Trauma Center (7.3% vs 3.9%) compared to falling indoors. Young and middle-aged patients who fell on streets or sidewalks had higher proportions for a T-RTS score indicating the need for Trauma Center care compared to those in this subgroup who fell indoors. Yet older patients injured by falling indoors were more likely to have a T-RTS score indicating the need for transport to a Trauma Center than older patients who fell on streets or sidewalks., Conclusions: There was a similar proportion of patients with severe injurious falls that occurred indoors and outdoors on streets or sidewalks. These findings suggest the need to determine outdoor environmental risks for outdoor falls to support location-specific interventions., (© 2024. The Author(s).)

Background: Early administration of adrenaline is associated with improved survival after out-of-hospital cardiac arrest (OHCA). Delays in vascular access may impact the timely delivery of adrenaline. Novel methods for administering adrenaline before vascular access may enhance survival. The objective of this study was to determine whether an initial intramuscular (IM) adrenaline dose followed by standard IV/IO adrenaline is associated with improved survival after OHCA., Methods Study Design: We conducted a before-and-after study of the implementation of an early, first-dose IM adrenaline EMS protocol for adult OHCAs. The pre-intervention period took place between January 2010 and October 2019. The post-intervention period was between November 2019 and May 2024., Setting: Single-center urban, two-tiered EMS agency., Participants: Adult, nontraumatic OHCA meeting criteria for adrenaline use., Intervention: Single dose (5 mg) IM adrenaline. All other care, including subsequent IV or IO adrenaline, followed international guidelines., Main Outcomes and Measures: The primary outcome was survival to hospital discharge. Secondary outcomes were time from EMS arrival to the first dose of adrenaline, survival to hospital admission, and favorable neurologic function at discharge., Results: Among 1405 OHCAs, 420 (29.9%) received IM adrenaline and 985 (70.1%) received usual care. Fifty-two patients received the first dose of adrenaline through the IV or IO route within the post-intervention period and were included in the standard care group analysis. Age was younger and bystander CPR was higher in the IM adrenaline group. All other characteristics were similar between IM and standard care cohorts. Time to adrenaline administration was faster for the IM cohort [(median 4.3 min (IQR 3.0-6.0) vs. 7.8 min (IQR 5.8-10.4)]. Compared with standard care, IM adrenaline was associated with improved survival to hospital admission (37.1% vs. 31.6%; aOR 1.37, 95% CI 1.06-1.77), hospital survival (11.0% vs 7.0%; aOR 1.73, 95% CI 1.10-2.71) and favorable neurologic status at hospital discharge (9.8% vs 6.2%; aOR 1.72, 95% CI 1.07-2.76)., Conclusion: In this single-center before-and-after implementation study, an initial IM dose of adrenaline as an adjunct to standard care was associated with improved survival to hospital admission, survival to hospital discharge, and functional survival. A randomized controlled trial is needed to fully assess the potential benefit of IM adrenaline delivery in OHCA., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Importance: Identifying longitudinal changes in advanced airway management by emergency medical services (EMS) is crucial for understanding practice patterns and optimizing care., Objective: To examine the longitudinal trends in endotracheal intubation (ETI) and supraglottic airway (SGA) utilization in a national EMS cohort., Design, Setting, and Participants: This retrospective cross-sectional study analyzed 2011 to 2022 data from the ESO Data Collaborative, a national database of US prehospital electronic health records. The study included all 911 EMS events in which advanced airway management was attempted. Data were analyzed from November 2022 to January 2024., Exposures: Advanced airway management attempts, including ETI, SGA, and surgical airways., Main Outcomes and Measures: The annual percentage of ETI and SGA attempts, stratified by underlying condition (cardiac arrest, nonarrest medical, nonarrest trauma, pediatrics)., Results: Among 47.5 million EMS activations, 444 041 (mean [SD] age, 60.6 [19.8] years; 273 296 [61.5%] men) involved advanced airway management, including 305 584 (68.8%) that used ETI and 200 437 (45.1%) that used SGA. The overall incidence was 9.3 per 1000 EMS events. In the cardiac arrest cohort from 2011 to 2022, EMS events with ETI attempts decreased from 2470 of 2831 (87.3%) to 40 083 of 72 793 (55.1%) and those with SGA attempts increased from 711 of 2831 (25.1%) to 44 386 of 72 793 (61.0%). In the pediatric subset, there were similarly large decreases in ETI attempts, from 117 of 182 EMS events (97.3%) to 1573 of 2307 EMS events (68.2%), and increases in SGA attempts, from 11 of 182 EMS events (6.6%) to 1058 of 2307 EMS events (45.9%). In the nonarrest medical and nonarrest trauma cohorts, ETI attempts decreased and SGA attempts increased but to a much lower extent., Conclusions and Relevance: In this national cross-sectional study of EMS care episodes, there were marked shifts in advanced airway management practices, with the increased use of SGA and decreased use of ETI. These observations highlight current trends in EMS airway management practices.

Background: Outcome selection is a critically important aspect of clinical trial design. Alive-and-ventilator free days is an outcome measure commonly used in critical care clinical trials, but has not been fully explored in resuscitation science., Methods: A simulation study was performed to explore approaches to the definition and analysis of alive-and-ventilator free days in cardiac arrest populations. Data from an in-hospital cardiac arrest observational cohort and from the Pragmatic Airway Resuscitation Trial were used to inform and conduct the simulations and validate approaches to alive-and-ventilator free days measurement and analysis., Findings: Alive-and-ventilator-free days is a flexible outcome measure in cardiac arrest populations. An approach to alive-and-ventilator free days that assigns -1 days when return of spontaneous circulation is not achieved provides a wider distribution of the outcome and improves statistical power. The optimal approach to the analysis of alive-and-ventilator free days varies based on the expected impact of the intervention under study on rates of return of spontaneous circulation, survival, and ventilator-free survival., Conclusions: Alive-and-ventilator free days adds to the armamentarium of clinical trialists in the field of resuscitation science., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Moskowitz et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: In the absence of a gold-standard diagnostic modality for cellulitis, sterile inflammatory disorders may be misdiagnosed as cellulitis., Objective: To determine the utility of skin biopsy and tissue culture for the diagnosis and management of patients admitted with a diagnosis of presumed cellulitis., Design: Pilot single-blind parallel group randomized controlled clinical trial in 56 patients with a primary diagnosis of presumed cellulitis. In the intervention group only, skin biopsy and tissue culture results were made available to the primary care team to guide diagnosis and management. Length of hospital stay and antibiotic use were evaluated as outcome measures., Results: Length of stay showed the greatest opportunity for further study as a primary outcome (intervention: 4, IQR (2-6) vs. control: 5 IQR (3-8) days; p = 0.124)., Limitations: The COVID-19 pandemic placed limitations on participant enrollment and study duration; in addition, data was collected from a single medical center., Conclusion: This study demonstrates that length of stay and anti-pseudomonal antibiotic de-escalation are endpoints that may be influenced by biopsy and tissue culture results in presumed cellulitis patients; these outcomes warrant further study., (© 2024. The Author(s).)

Study Objective: Airway management is a crucial part of out-of-hospital care. It is not known if the rate of overall agency intubation attempts is associated with intubation success. We sought to evaluate the association between agency intubation attempt rate and intubation success using a national out-of-hospital database., Methods: We conducted a retrospective secondary analysis of the ESO Data Collaborative from 2018 to 2019, and included all adult cases with an endotracheal intubation attempt. We calculated the number of intubations attempted per 100 responses, advanced life support responses, and transports for each agency. We excluded cases originating at health care facilities and outliers. We used multivariable logistic regression to evaluate the association between agency intubation attempt rate and 1) intubation success and 2) first-pass success. We adjusted for confounders., Results: We included 1,005 agencies attempting 58,509 intubations. Overall, the intubation success rate was 78.8%, and the first-pass success rate was 68.5%. Per agency, the median rate of intubation attempts per 100 emergency medical service responses was 0.8 (interquartile range 0.6 to 1.1). Rates of intubation attempts per 100 responses (adjusted odds ratio [aOR] 1.7; 95% confidence interval [CI] 1.6 to 1.8), advanced life support responses (aOR 1.18; 95% CI 1.16 to 1.20), and transports (aOR 1.21; 95% CI 1.18 to 1.22) were all associated with intubation success. These relationships were similar for first-pass success but with smaller effect sizes., Conclusion: Higher agency rates of intubation attempts were associated with increased rates of intubation success and first-pass success., (Copyright © 2023 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Importance: While widely measured, the time-varying association between exhaled end-tidal carbon dioxide (EtCO2) and out-of-hospital cardiac arrest (OHCA) outcomes is unclear., Objective: To evaluate temporal associations between EtCO2 and return of spontaneous circulation (ROSC) in the Pragmatic Airway Resuscitation Trial (PART)., Design, Setting, and Participants: This study was a secondary analysis of a cluster randomized trial performed at multicenter emergency medical services agencies from the Resuscitation Outcomes Consortium. PART enrolled 3004 adults (aged ≥18 years) with nontraumatic OHCA from December 1, 2015, to November 4, 2017. EtCO2 was available in 1172 cases for this analysis performed in June 2023., Interventions: PART evaluated the effect of laryngeal tube vs endotracheal intubation on 72-hour survival. Emergency medical services agencies collected continuous EtCO2 recordings using standard monitors, and this secondary analysis identified maximal EtCO2 values per ventilation and determined mean EtCO2 in 1-minute epochs using previously validated automated signal processing. All advanced airway cases with greater than 50% interpretable EtCO2 signal were included, and the slope of EtCO2 change over resuscitation was calculated., Main Outcomes and Measures: The primary outcome was ROSC determined by prehospital or emergency department palpable pulses. EtCO2 values were compared at discrete time points using Mann-Whitney test, and temporal trends in EtCO2 were compared using Cochran-Armitage test of trend. Multivariable logistic regression was performed, adjusting for Utstein criteria and EtCO2 slope., Results: Among 1113 patients included in the study, 694 (62.4%) were male; 285 (25.6%) were Black or African American, 592 (53.2%) were White, and 236 (21.2%) were another race; and the median (IQR) age was 64 (52-75) years. Cardiac arrest was most commonly unwitnessed (n = 579 [52.0%]), nonshockable (n = 941 [84.6%]), and nonpublic (n = 999 [89.8%]). There were 198 patients (17.8%) with ROSC and 915 (82.2%) without ROSC. Median EtCO2 values between ROSC and non-ROSC cases were significantly different at 10 minutes (39.8 [IQR, 27.1-56.4] mm Hg vs 26.1 [IQR, 14.9-39.0] mm Hg; P < .001) and 5 minutes (43.0 [IQR, 28.1-55.8] mm Hg vs 25.0 [IQR, 13.3-37.4] mm Hg; P < .001) prior to end of resuscitation. In ROSC cases, median EtCO2 increased from 30.5 (IQR, 22.4-54.2) mm HG to 43.0 (IQR, 28.1-55.8) mm Hg (P for trend < .001). In non-ROSC cases, EtCO2 declined from 30.8 (IQR, 18.2-43.8) mm Hg to 22.5 (IQR, 12.8-35.4) mm Hg (P for trend < .001). Using adjusted multivariable logistic regression with slope of EtCO2, the temporal change in EtCO2 was associated with ROSC (odds ratio, 1.45 [95% CI, 1.31-1.61])., Conclusions and Relevance: In this secondary analysis of the PART trial, temporal increases in EtCO2 were associated with increased odds of ROSC. These results suggest value in leveraging continuous waveform capnography during OHCA resuscitation., Trial Registration: ClinicalTrials.gov Identifier: NCT02419573.

Objective: To describe the distribution of alcohol and drug involvement in injurious falls by location and subtype of fall., Methods: Using the 2019 National Emergency Medical Services Information System (NEMSIS) dataset we identified 1,854,909 patients injured from falls requiring an Emergency Medical Services (EMS) response and determined the fall location (e.g. indoors or on street/sidewalk) and the EMS clinician's notation of alcohol or drug involvement. We analyzed substance involvement by fall subtype, location of fall and patient demographics., Results: Overall, for 7.4% of injurious falls there was a notation of substance use: 6.5% for alcohol alone, 0.6% for drugs and 0.3% for alcohol and drugs. 21.2% of falls that occurred on a street or sidewalk had a notation of substance use; alcohol use alone for 18.5% of falls, drugs alone for 1.7% of falls and alcohol and drugs for 0.9% of falls. Substance use prevalence was highest, at 30.3%, in the age group 21 to 64 years, for falls occurring on streets and sidewalks, without syncope or heat illness as contributing factors; alcohol use alone for 26.3%, drugs alone for 2.6%, and alcohol and drugs for 1.4%. Reported substance use involvement was more frequent for men compared to women for each location type., Conclusions: Overall, 1-in-5 injurious falls on streets and sidewalks and requiring EMS attention involved substance use, and these numbers likely underestimate the true burden. As cities seek to expand nightlife districts, design strategies to protect pedestrians from falls should be enacted.

Objectives: To determine the diagnostic accuracy of a rapid host-protein test for differentiating bacterial from viral infections in patients who presented to the emergency department (ED) or urgent care center (UCC)., Methods: This was a prospective multicenter, blinded study. MeMed BV (MMBV), a test based on tumor necrosis factor-related apoptosis-inducing ligand (TRAIL), interferon gamma-inducible protein-10 (IP-10), and C-reactive protein (CRP), was measured using a rapid measurement platform. Patients were enrolled from 9 EDs and 3 UCCs in the United States and Israel. Patients >3 months of age presenting with fever and clinical suspicion of acute infection were considered eligible. MMBV results were not provided to the treating clinician. MMBV results (bacterial/viral/equivocal) were compared against a reference standard method for classification of infection etiology determined by expert panel adjudication. Experts were blinded to MMBV results. They were provided with comprehensive patient data, including laboratory, microbiological, radiological and follow-up., Results: Of 563 adults and children enrolled, 476 comprised the study population (314 adults, 162 children). The predominant clinical syndrome was respiratory tract infection (60.5% upper, 11.3% lower). MMBV demonstrated sensitivity of 90.0% (95% confidence interval [CI]: 80.3-99.7), specificity of 92.8% (90.0%-95.5%), and negative predictive value of 98.8% (96.8%-99.6%) for bacterial infections. Only 7.2% of cases yielded equivocal MMBV scores. Area under the curve for MMBV was 0.95 (0.90-0.99)., Conclusions: MMBV had a high sensitivity and specificity relative to reference standard for differentiating bacterial from viral infections. Future implementation of MMBV for patients with suspected acute infections could potentially aid with appropriate antibiotic decision-making., Competing Interests: Cesar A. Arias, Natasha Ballard, Karen C. Carroll, Andrea T. Cruz, Richard Gordon, Salim Halabi, Jeffrey D. Harris, Kristina G. Hulten, Theresa Jacob, Mark D. Kellogg, Adi Klein, Pninit Shaked Mishan, Sergey M. Motov, Octavia M. Peck‐Palmer, Leticia M. Ryan, Ma'anit Shapira, George S. Suits, Henry E. Wang, Alexandra Weissman, and Richard E. Rothman have no relevant conflict of interests to declare. Richard G. Bachur and Sheldon L. Kaplan participated in a scientific advisory board on health economic modeling for MeMed and were compensated for their time. Richard E. Rothman participated in a scientific board on health care economic modeling (without compensation). Richard G. Bachur, Sheldon L. Kaplan, and Richard E. Rothman participated in discussions with the U.S. Food and Drug Administration clearance and were involved in study design, patient recruitment, data collection and analysis, and drafting and revising the manuscript., (© 2024 The Authors. Journal of the American College of Emergency Physicians Open published by Wiley Periodicals LLC on behalf of American College of Emergency Physicians.)

Objectives: Persons 65 years and older (older persons), particularly residents of nursing homes (NHs), disproportionately access the emergency department (ED) and utilize more medical resources. The goal of this study is to provide a contemporary description of healthcare utilization patterns and disposition decisions for United States (US) NH residents presenting to EDs., Methods: Older persons presenting to EDs in the US were identified in the National Hospital Ambulatory Medical Care Survey (NHAMCS) 2017, 2018 and 2019 datasets. We examined demographic, clinical, and resource use characteristics and outcomes. After survey weighting, we compared the frequency of different imaging, medications, clinical interventions, and outcomes in the ED between NH residents and those residing outside NHs., Results: From 2017 to 2019, older persons made 24,441,285 annual visits to the ED, comprising 17.5% of all visits. Among these, 1,579,916 visits (6.5%) were by NH residents. Compared with non-NH residents, NH residents were older (mean age: 81.2 [95%CI 81.5-82.9] vs 76.1 [95%CI 75.8-76.4]), underwent more imaging (82.8% [95%CI 79.5-86.1] vs 71.6% [95%CI 69.9-73.3]), were administered fewer potentially inappropriate medications (PIMs) in the ED or upon discharge (9.5% [95%CI 6.2-2.7] vs 17.1% [95%CI 15.8-18.4]), and had a higher proportion of visits resulting in hospital admission (44.1% [95%CI 38.2-49.9] vs 26.0% [95%CI 23.3, 28.7])., Conclusions: Older NH residents presenting to the ED use more resources and are more likely to be hospitalized compared to older persons residing outside NHs. The resource-intensive nature of these visits highlights the importance of targeted, multi-disciplinary interventions that optimize ED care for this population., Competing Interests: Declaration of competing interest This manuscript represents the views of the authors and does not necessarily represent the views of the Department of Veterans Affairs or the US government. JD receives personal fees from the American College of Emergency Physicians as a methodology/statistics editor for Annals of Emergency Medicine., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objectives: Traumatic brain injury (TBI) is an important public health problem resulting in significant death and disability. Emergency medical services (EMS) personnel often provide initial treatment for TBI, but only limited data describe the long-term course and outcomes of this care. We sought to characterize changes in neurologic status among adults with TBI patients enrolled in the Resuscitation Outcomes Consortium Hypertonic Saline (ROC-HS) trial., Methods: We used data from the TBI cohort of the ROC-HS trial. The trial included adults with TBI, with Glasgow Coma Scale (GCS) ≤8, and excluded those with shock (systolic blood pressure [SBP] ≤70 or SBP 71-90 with a heart rate [HR] ≥108). The primary outcome was Glasgow Outcome Scale-Extended (GOS-E; 1 = dead, 8 = no disability) determined at (a) hospital discharge and (b) 6-month follow-up. We assessed changes in GOS-E between hospital discharge and 6-month follow-up using descriptive statistics and Sankey graphs., Results: Among 1279 TBI included in the analysis, GOS-E categories at hospital discharge were as follows: favorable (GOS-E 5-8) 220 (17.2%), unfavorable (GOS-E 2-4) 664 (51.9%), dead (GOS-E 1) 321 (25.1%), and missing 74 (5.8%). GOS-E categories at 6-month follow-up were as follows: favorable 459 (35.9%), unfavorable 279 (21.8%), dead 346 (27.1%), and missing 195 (15.2%). Among initial TBI survivors with complete GOS-E, >96% followed one of three neurologic recovery patterns: (1) favorable to favorable (20.0%), (2) unfavorable to favorable (40.3%), and (3) unfavorable to unfavorable (36.0%). Few patients deteriorated from favorable to unfavorable neurologic status, and there were few additional deaths., Conclusions: Among TBI receiving initial prehospital care in the ROC-HS trial, changes in 6-month neurologic status followed distinct patterns. Among TBI with unfavorable neurologic status at hospital discharge, almost half improved to favorable neurologic status at 6 months. Among those with favorable neurologic status at discharge, very few worsened or died at 6 months. These findings have important implications for TBI clinical care, research, and trial design., Competing Interests: There is no overlap with previous publications other than the parent Resuscitation Outcomes Consortium Hypertonic Saline trial, and we confirm that the manuscript, including related data, figures, and tables, has not been published previously and that the manuscript is not under consideration elsewhere at this time. Dr. Wang is Editor in Chief of JACEP Open and had no role in the editorial assessment of or decision to publish this article., (© 2024 The Authors. Journal of the American College of Emergency Physicians Open published by Wiley Periodicals LLC on behalf of American College of Emergency Physicians.)

Acute respiratory failure is a common reason for emergency department visits and hospital admissions. Diverse underlying physiologic abnormalities lead to unique aspects about the most common causes of acute respiratory failure: acute decompensated heart failure, acute exacerbation of chronic obstructive pulmonary disease, and acute de novo hypoxemic respiratory failure. Noninvasive respiratory support strategies are increasingly used methods to support work of breathing and improve gas exchange abnormalities to improve outcomes relative to conventional oxygen therapy or invasive mechanical ventilation. Noninvasive respiratory support includes noninvasive positive pressure ventilation and nasal high flow, each with unique physiologic mechanisms. This paper will review the physiology of respiratory failure and noninvasive respiratory support modalities and offer data and guideline-driven recommendations in the context of key clinical controversies., Competing Interests: J. M. and H. E. W. have received travel support from Fisher & Paykel., (© 2024 The Authors. Journal of the American College of Emergency Physicians Open published by Wiley Periodicals LLC on behalf of American College of Emergency Physicians.)

Pedestrian injuries from falls are an understudied cause of morbidity. Here, we compare the burden of pedestrian injuries from falls occurring on streets and sidewalks with that from motor vehicle collisions. Data on injurious falls on streets and sidewalks, and pedestrian-motor vehicle collisions, to which Emergency Medical Services responded, along with pedestrian and incident characteristics, were identified in the 2019 National Emergency Medical Services Information System database. In total, 118,520 injurious pedestrian falls and 33,915 pedestrians-motor vehicle collisions were identified, with 89% of the incidents occurring in urban areas. Thirty-two percent of pedestrians struck by motor vehicles were coded as Emergent or Critical by Emergency Medical Services, while 19% of pedestrians injured by falls were similarly coded. However, the number of pedestrians whose acuity was coded as Emergent or Critical was 2.1 times as high for injurious falls as compared with pedestrians-motor vehicle collisions. This ratio was 3.9 for individuals 50 years and older and 6.1 for those 65 years and older. In conclusion, there has been substantial and appropriate policy attention given to preventing pedestrian injuries from motor vehicles, but disproportionately little to pedestrian falls. However, the population burden of injurious pedestrian falls is significantly greater and justifies an increased focus on outdoor falls prevention, in addition to urban design, policy, and built environment interventions to reduce injurious falls on streets and sidewalks, than currently exists across the USA., (© 2024. The New York Academy of Medicine.)

Objective: Mobile integrated health care (MIH) leverages emergency medical services (EMS) clinicians to perform local health care functions. Little is known about the individual EMS clinicians working in this role. We sought to describe the prevalence, demographics, and training of EMS clinicians providing MIH in the United States (US)., Methods: This is a cross-sectional study of US-based, nationally certified civilian EMS clinicians who completed the National Registry of Emergency Medical Technicians (NREMT) recertification application during the 2021-2022 cycle and completed the voluntary workforce survey. Workforce survey respondents self-identified their job roles within EMS, including MIH. If an MIH role was selected, additional questions clarified the primary role in EMS, type of MIH provided, and hours of MIH training received. We merged the workforce survey responses with the individual's NREMT recertification demographic profile. The prevalence of EMS clinicians with MIH roles and data on demographics, clinical care provided, and MIH training were calculated using descriptive statistics, including proportions with associated binomial 95% confidence intervals (CI)., Results: Of 38,960 survey responses, 33,335 met inclusion criteria and 490 (1.5%; 95%CI 1.3-1.6%) EMS clinicians indicated MIH roles. Of these, 62.0% (95%CI 57.7-66.3%) provided MIH as their primary EMS role. EMS clinicians with MIH roles were present in all 50 states and certification levels included emergency medical technician (EMT) (42.8%; 95%CI 38.5-47.2%), advanced emergency medical technician (AEMT) (3.5%; 95%CI 1.9-5.1%), and paramedic (53.7%; 95%CI 49.3-58.1%). Over one-third (38.6%; 95%CI 34.3-42.9%) of EMS clinicians with MIH roles received bachelor's degrees or above, and 48.4% (95%CI 43.9%-52.8%) had been in their MIH roles for less than 3 years. Nearly half (45.6%; 95%CI 39.8-51.6%) of all EMS clinicians with primary MIH roles received less than 50 hours (h) of MIH training; only one-third (30.0%; 95%CI 24.7-35.6%) received more than 100 h of training., Conclusion: Few nationally certified US EMS clinicians perform MIH roles. Only half of MIH roles were performed by paramedics; EMT and AEMT clinicians performed a substantial proportion of MIH roles. The observed variability in certification and training suggest heterogeneity in preparation and performance of MIH roles among US EMS clinicians.

Objective: Public health surveillance is essential for improving community health. The Cardiac Arrest Registry to Enhance Survival (CARES) is a surveillance system for out-of-hospital cardiac arrest (OHCA). We describe results of the organized statewide implementation of Ohio CARES., Methods: We performed a retrospective analysis of CARES enactment in Ohio. Key elements included: establishment of statewide leadership, appointment of a dedicated coordinator, conversion to a statewide subscription, statewide dissemination of information, fundraising from internal and external stakeholders, and conduct of resuscitation academies. We identified all adult (≥18 years) OHCA reported in the registry during 2013-2020. We evaluated OHCA characteristics before (2013-2015) and after (2016-2019) statewide implementation using chi-square test. We evaluated trends in OHCA outcomes using the Cochran-Armitage test of trend., Results: Statewide CARES promotion increased participation from 2 (urban) to 136 (129 urban, 7 rural) EMS agencies. Covered population increased from 1.2 M (10% of state) to 4.8 M (41% of state). After statewide implementation, OHCA populations increased male (58.1% vs 60.8%, p < 0.01), white (50.1% vs 63.7%, p < 0.01), bystander witnessed (26.9% vs 32.9%, p < 0.01) OHCAs. Bystander CPR (34.7% vs 33.2%, p = 0.22), bystander AED (13.5% vs 12.3%, p = 0.55) and initial rhythm (shockable 18.0% vs 18.3%, p = 0.32) did not change. From 2013 to 2019 there were temporal increases in ROSC (29.7% to 31.9%, p-trend = 0.028), survival (7.4% to 12.3%, p-trend < 0.001) and survival with good neurologic outcome (5.6% to 8.6%, p-trend = 0.047)., Conclusion: The organized statewide implementation of CARES in Ohio was associated with marked increases in community uptake and concurrent observed improvements in patient outcomes. These results highlight key lessons for community-wide fostering of OHCA surveillance., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Background: Few studies have measured ventilation during early cardiopulmonary resuscitation (CPR) before advanced airway placement. Resuscitation guidelines recommend pauses after every 30 chest compressions to deliver ventilations. The effectiveness of bag-valve-mask ventilation delivered during the pause in chest compressions is unknown. We sought to determine: (1) the incidence of lung inflation with bag-valve-mask ventilation during 30:2 CPR; and (2) the association of ventilation with outcomes after out-of-hospital cardiac arrest., Methods: We studied patients with out-of-hospital cardiac arrest from 6 sites of the Resuscitation Outcomes Consortium CCC study (Trial of Continuous Compressions versus Standard CPR in Patients with Out-of-Hospital Cardiac Arrest). We analyzed patients assigned to the 30:2 CPR arm with ≥2 minutes of thoracic bioimpedance signal recorded with a cardiac defibrillator/monitor. Detectable ventilation waveforms were defined as having a bioimpedance amplitude ≥0.5 Ω (corresponding to ≥250 mL V T ) and a duration ≥1 s. We defined a chest compression pause as a 3- to 15-s break in chest compressions. We compared the incidence of ventilation and outcomes in 2 groups: patients with ventilation waveforms in <50% of pauses (group 1) versus those with waveforms in ≥50% of pauses (group 2)., Results: Among 1976 patients, the mean age was 65 years; 66% were male. From the start of chest compressions until advanced airway placement, mean±SD duration of 30:2 CPR was 9.8±4.9 minutes. During this period, we identified 26 861 pauses in chest compressions; 60% of patients had ventilation waveforms in <50% of pauses (group 1, n=1177), and 40% had waveforms in ≥50% of pauses (group 2, n=799). Group 1 had a median of 12 pauses and 2 ventilations per patient versus group 2, which had 12 pauses and 12 ventilations per patient. Group 2 had higher rates of prehospital return of spontaneous circulation (40.7% versus 25.2%; P <0.0001), survival to hospital discharge (13.5% versus 4.1%; P <0.0001), and survival with favorable neurological outcome (10.6% versus 2.4%; P <0.0001). These associations persisted after adjustment for confounders., Conclusions: In this study, lung inflation occurred infrequently with bag-valve-mask ventilation during 30:2 CPR. Lung inflation in ≥50% of pauses was associated with improved return of spontaneous circulation, survival, and survival with favorable neurological outcome., Competing Interests: Disclosures Dr Idris receives grant support from the US National Institutes of Health (NIH) and the Centers for Disease Control and Prevention. He serves as an unpaid volunteer on the American Heart Association national emergency cardiovascular care committee and the Stryker, Inc. (Belfast) clinical advisory board. Dr Kudenchuk receives grant support from NIH as institutional principal investigator for the SIREN Network. Dr Wang received research funds from NIH and the US Department of Defense, site research funds from Marinus, Vasomune, and Quidel, travel funds from Fisher-Paykel, Inc., and consulting fees from the American College of Emergency Physicians as the editor in chief of JACEP Open.

Guidelines for the management of in-hospital cardiac arrest resuscitation are often drawn from evidence generated in out-of-hospital cardiac arrest populations and applied to the in-hospital setting. Approach to airway management during resuscitation is one example of this phenomenon, with the recommendation to place either a supraglottic airway or endotracheal tube when performing advanced airway management during in-hospital cardiac arrest based mainly in clinical trials conducted in the out-of-hospital setting. The Hospital Airway Resuscitation Trial (HART) is a pragmatic cluster-randomized superiority trial comparing a strategy of first choice supraglottic airway to a strategy of first choice endotracheal intubation during resuscitation from in-hospital cardiac arrest. The design includes a number of innovative elements such as a highly pragmatic design drawing from electronic health records and a novel primary outcome measure for cardiac arrest trials-alive-and-ventilator free days. Many of the topics explored in the design of HART have wide relevance to other trials in in-hospital cardiac arrest populations., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Ari Moskowitz, Michelle Gong, Michael Donnino, David Esses, Mimi Kim, Ariel Shiloh, Daniel Fein, Samuel Rednor, and Henry Wang report financial support was provided by National Institutes of Health., (© 2023 The Author(s).)

Cellulitis is the most common cause for skin disease hospitalization with costs totaling over $7 billion. It can be challenging to diagnose due to clinical similarities with other inflammatory conditions and the lack of a gold-standard diagnostic test. This article reviews the different testing methods for the diagnosis of non-purulent cellulitis based on three categories (1) clinical scoring assessments, (2) in vivo imaging techniques, and (3) laboratory assessments., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Study Objective: To evaluate racial and ethnic disparities in out-of-hospital analgesic administration, accounting for the influence of clinical characteristics and community socioeconomic vulnerability, among a national cohort of patients with long bone fractures., Methods: Using the 2019-2020 ESO Data Collaborative, we retrospectively analyzed emergency medical services (EMS) records for 9-1-1 advanced life support transport of adult patients diagnosed with long bone fractures at the emergency department. We calculated adjusted odds ratios (aOR) and 95% confidence intervals (CI) for out-of-hospital analgesic administration by race and ethnicity, accounting for age, sex, insurance, fracture location, transport time, pain severity, and scene Social Vulnerability Index. We reviewed a random sample of EMS narratives without analgesic administration to identify whether other clinical factors or patient preferences could explain differences in analgesic administration by race and ethnicity., Results: Among 35,711 patients transported by 400 EMS agencies, 81% were White, non-Hispanic, 10% were Black, non-Hispanic, and 7% were Hispanic. In crude analyses, Black, non-Hispanic patients with severe pain were less likely to receive analgesics compared with White, non-Hispanic patients (59% versus 72%; Risk Difference: -12.5%, 95% CI: -15.8% to -9.9%). After adjustment, Black, non-Hispanic patients remained less likely to receive analgesics compared with White, non-Hispanic patients (aOR:0.65, 95% CI:0.53 to 0.79). Narrative review identified similar rates of patients declining analgesics offered by EMS and analgesic contraindications across racial and ethnic groups., Conclusions: Among EMS patients with long bone fractures, Black, non-Hispanic patients were substantially less likely to receive out-of-hospital analgesics compared with White, non-Hispanic patients. These disparities were not explained by differences in clinical presentations, patient preferences, or community socioeconomic conditions., (Copyright © 2023 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Objective: Although 911 calls for acute shortness of breath are common, the role of emergency medical services (EMS) in acute asthma care is unclear. We sought to characterize the demographics, course, and outcomes of adult emergency department (ED) patients with asthma in the United States receiving initial EMS care., Methods: We analyzed data from the 2016-2019 National Hospital Ambulatory Medical Care Survey (NHAMCS). We included patients aged ≥18 years with an ED visit diagnosis of asthma, stratifying the cases according to initial EMS care. Accounting for the survey design of NHAMCS, we generated nationalized estimates of the number of EMS and non-EMS asthma visits. Using logistic regression, we determined the associations between initial EMS care and patient demographics (age, sex, race, and insurance type), ED course (initial vital signs, triage category, testing, medications), and outcomes (hospital admission, ED length of stay)., Results: Of 435 million adult ED visits during 2016-2019, there were ≈5.3 million related to asthma (1.3 million annually, 1.2%; 95% confidence interval [CI], 1.1%-1.4%). A total of 602,569 (150,642 annually, 11.3%; 95% CI, 8.6%-14.8%) ED patients with asthma received initial EMS care. Compared with non-EMS asthma patients, EMS asthma patients were more likely to present with an "urgent" ED triage category (odds ratio [OR], 22.2; 95% CI, 6.6-74.9) and to undergo laboratory (OR, 2.78; 95% CI, 1.41-5.46) or imaging tests (OR, 2.42; 95% CI, 1.21-4.83). ED patients with asthma receiving initial EMS care were almost 3 times more likely to be admitted to the hospital (OR, 2.81; 95% CI, 1.27-6.25). There were no differences in demographics, ED use of β-agonists or corticosteroids, or ED length of stay between EMS and non-EMS asthma patients., Conclusions: Approximately 1 in 10 adult ED patients with asthma receive initial care by EMS. EMS asthma patients present to the ED with higher acuity, undergo more diagnostic testing in the ED, and are more likely to be admitted. Although limited in information regarding the prehospital course, these findings highlight the more severe illness of asthma patients transported by EMS and underscore the importance of EMS in emergency asthma care., Competing Interests: Dr. Wang is Editor in Chief of JACEP Open. Dr. Wang had no role in the editorial evaluation of this manuscript., (© 2023 The Authors. JACEP Open published by Wiley Periodicals LLC on behalf of American College of Emergency Physicians.)

Feedback on ventilation could help improve cardiopulmonary resuscitation quality and survival from out-of-hospital cardiac arrest (OHCA). However, current technology that monitors ventilation during OHCA is very limited. Thoracic impedance (TI) is sensitive to air volume changes in the lungs, allowing ventilations to be identified, but is affected by artifacts due to chest compressions and electrode motion. This study introduces a novel algorithm to identify ventilations in TI during continuous chest compressions in OHCA. Data from 367 OHCA patients were included, and 2551 one-minute TI segments were extracted. Concurrent capnography data were used to annotate 20724 ground truth ventilations for training and evaluation. A three-step procedure was applied to each TI segment: First, bidirectional static and adaptive filters were applied to remove compression artifacts. Then, fluctuations potentially due to ventilations were located and characterized. Finally, a recurrent neural network was used to discriminate ventilations from other spurious fluctuations. A quality control stage was also developed to anticipate segments where ventilation detection could be compromised. The algorithm was trained and tested using 5-fold cross-validation, and outperformed previous solutions in the literature on the study dataset. The median (interquartile range, IQR) per-segment and per-patient F 1 -scores were 89.1 (70.8-99.6) and 84.1 (69.0-93.9), respectively. The quality control stage identified most low performance segments. For the 50% of segments with highest quality scores, the median per-segment and per-patient F 1 -scores were 100.0 (90.9-100.0) and 94.3 (86.5-97.8). The proposed algorithm could allow reliable, quality-conditioned feedback on ventilation in the challenging scenario of continuous manual CPR in OHCA.

Background: The Emergency Department (ED) plays a key role in the identification and care of acute medical conditions, including cancer. In this scoping review, we aimed to determine the role of the ED in the acute diagnosis of cancer., Methods: We conducted a scoping review of articles according to Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) using PubMed and Google Scholar. We screened studies of adults with a new diagnosis of cancer in the ED. We included randomized control trials, prospective, retrospective, and cross-sectional observational studies, and case reports published in English since 2000. We grouped the articles into categories based on their objectives and findings., Results: Of the 4459 articles, we included 47 in the review. The identified studies fell into three major categories: (1) studies describing the incidental diagnosis of cancer in the ED (n = 11, 23%), (2) studies characterizing the acute initial presentation of cancer in the ED (n = 19, 41%), and (3) studies describing the ED as a pathway to cancer diagnosis in the healthcare system (n = 17, 36%). Across the studies, cancer diagnoses in the ED were more likely in patients with higher comorbidities, occurred at later stages, and resulted in worse survival rates., Conclusions: The ED plays a prominent role in the initial diagnosis of cancer. Efforts must be made to integrate the ED within the cancer care continuum., (© 2023 The Authors. Cancer Medicine published by John Wiley & Sons Ltd.)

Objective: Ventilation control is important during resuscitation from out-of-hospital cardiac arrest (OHCA). We compared different methods for calculating ventilation rates (VR) during OHCA., Methods: We analyzed data from the Pragmatic Airway Resuscitation Trial, identifying ventilations through capnogram recordings. We determined VR by: 1) counting the number of breaths within a time epoch ("counted" VR), and 2) calculating the mean of the inverse of measured time between breaths within a time epoch ("measured" VR). We repeated the VR estimates using different time epochs (10, 20, 30, 60 sec). We defined hypo- and hyperventilation as VR <6 and >12 breaths/min, respectively. We assessed differences in estimated hypo- and hyperventilation with each VR measurement technique., Results: Of 3,004 patients, data were available for 1,010. With the counted method, total hypoventilation increased with longer time epochs ([10-s epoch: 75 sec hypoventilation] to [60-s epoch: 97 sec hypoventilation]). However, with the measured method, total hypoventilation decreased with longer time epochs ([10-s epoch: 223 sec hypoventilation] to [60-s epoch: 150 sec hypoventilation]). With the counted method, the total duration of hyperventilation decreased with longer time epochs ([10-s epochs: 35 sec hyperventilation] to [60-s epoch: 0 sec hyperventilation]). With the measured method, total hyperventilation decreased with longer time epochs ([10-s epoch: 78 sec hyperventilation] to [60-s epoch: 0 sec hyperventilation]). Differences between the measured and counted estimates were smallest with a 60-s time epoch., Conclusions: Quantifications of hypo- and hyperventilation vary with the applied measurement methods. Measurement methods are important when characterizing ventilation rates in OHCA., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Graham Nichol has research funding from Abiomed Inc. (Danvers, MA), Vapotherm Inc. (Exeter, NH), and ZOLL Medical (Chelmsford, MA). He is a member of the steering committee of the PRINCESS 2 Trial of Ultrafast Hypothermia After Cardiac Arrest. He is also a consultant to CPR Therapeutics (Putney, VT), Heartbeam Inc. (Santa Clara, CA), Kestra Medical Technologies Inc. (Kirkland, WA), Invero Health LLC. (Montvale, NJ), Orixha Inc. (Saint Cyr Au Mont d’Or, France), and ZOLL Circulation (San Jose, CA)., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Pre-hospital resuscitation of critically injured patients traditionally includes supplemental oxygen therapy to address potential hypoxemia. The objective of this study was to explore the association between pre-hospital hypoxemia, hyperoxemia, and mortality in patients with traumatic brain injury (TBI) and traumatic shock. We hypothesized that both hypoxemia and hyperoxemia would be associated with increased mortality. We used the Resuscitation Outcomes Consortium Prospective Observational Prehospital and Hospital Registry for Trauma (ROC PROPHET) database of critically injured patients to identify a severe TBI cohort (pre-hospital Glasgow Coma Scale [GCS] 3-8) and a traumatic shock cohort (systolic blood pressure ≤90 mm Hg and pre-hospital GCS >8). Arterial blood gas (ABG) obtained within 30 min of hospital arrival was required for inclusion. Patients with hypoxemia (PaO 2 <80 mm Hg) and hyperoxemia (PaO 2 >400 mm Hg) were compared to those with normoxemia (PaO 2 80-400 mm Hg) with regard to the primary outcome measure of in-hospital mortality in both the TBI and traumatic shock cohorts. Multiple logistic regression was used to calculate odds ratios (ORs) after adjustment for multiple covariables. In addition, regression spline curves were generated to estimate the risk of death as a continuous function of PaO 2 levels. A total of 1248 TBI patients were included, of whom 396 (32%) died before hospital discharge. Associations between hypoxemia and increased mortality (OR, 1.8; 95% confidence interval [CI], 1.2-2.8; p  = 0.008) and between hyperoxemia and decreased mortality (OR, 0.6; 95% CI, 0.4-0.9; p  = 0.018) were observed. A total of 582 traumatic shock patients were included, of whom 52 (9%) died before hospital discharge. No statistically significant associations were observed between in-hospital mortality and either hypoxemia (OR, 1.0; 95% CI, 0.4-2.4; p  = 0.987) or hyperoxemia (OR, 1.9; 95% CI, 0.6-5.7; p  = 0.269). Among patients with severe TBI but not traumatic shock, hypoxemia was associated with an increase of in-hospital mortality and hyperoxemia was associated with a decrease of in-hospital mortality., Competing Interests: No competing financial interests exist., (© Daniel P. Davis et al., 2023; Published by Mary Ann Liebert, Inc.)

Background: Falls are a common cause of injury with significantly associated medical costs yet public health surveillance of injuries from falls is underdeveloped. In addition, the epidemiologic understanding of outdoor falls, which have been reported to account for 47% of all injurious falls, is scant. Here we present methods to use emergency medical services (EMS) data as a public health surveillance tool for fall injuries, including those that occur secondary to syncope and heat illness, with a focus on the scope and epidemiology of outdoor fall injuries., Methods: Using the 2019 National Emergency Medical Services Information System (NEMSIS) data, we developed an approach to identify EMS encounters for fall injuries, syncope and heat illness. NEMSIS variables used in our algorithm included the EMS respondent's impression of the encounter, the reported major symptoms and the cause of injury. With these data we identified injuries from falls and, using the NEMSIS data on the location of the encounter, we identified fall injuries as occurring indoors or outdoors. We present the descriptive epidemiology of the identified patients., Results: There were 1,854,909 injuries from falls that required an EMS response identified in the NEMSIS data, with 4% of those injuries secondary to episodes of syncope (n = 73,126) and heat illness. Sufficient data were available from 94% of injurious falls that they could be assigned to indoor or outdoor locations, with 9% of these fall injuries occurring outdoors. Among fall injuries identified as occurring outdoors, 85% occurred on streets and sidewalks. Patient age was the primary sociodemographic characteristic that varied by location of the injurious fall. Sixty-six percent of fall injuries that occurred indoors were among those age 65 years or older, while this figure was 34% for fall injuries occurring outdoors on a street or sidewalk., Conclusion: The occurrence of outdoor fall injuries identified in the NEMSIS data were substantially lower than reported in other data sets. However, numerically fall injuries occurring outdoors represent a substantial public health burden. The strengths and weaknesses of using this approach for routine public health surveillance of injuries from falls, syncope and heat illness are discussed., (© 2023. The Author(s).)

Objective: Emergency medical services (EMS) play a key role in access to prehospital emergency care. While EMS has defined levels of certification, the roles in the care paradigm fulfilled by these clinicians vary. The aim of this study is to describe the national differences between EMS clinicians with primary non-patient care vs. patient care roles., Methods: We performed a cross sectional evaluation of nationally certified EMS clinicians in the United States who recertified in 2020. As part of the recertification process, applicants voluntarily complete profile questions regarding demographic, job, and service characteristics. We compared the characteristics between individuals self-reporting primary patient care roles vs. non-patient care roles. Using logistic regression, we determined independent predictors for having a non-patient care role., Results: In 2020, 126,038 people completed recertification. Of the 96,661 completing the profile, 80,591 (83.4%) indicated that they provided patient care, and 16,070 (16.6%) did not provide patient care as a primary role. Non-patient care personnel were more likely to be older (median 43 years old vs 34 years old), and to have a higher level of education (bachelor's degree or more: OR 2.25, 95%CI [2.13-2.38]) compared with patient care practitioners. Non-patient care personnel were less likely to be female (0.67 [0.64-0.70]) and minorities (OR 0.80 [0.76-0.84]). Non-patient care personnel reported longer work experience (16 years or more: OR 6.30 [5.98-6.64]), were less likely to hold part time positions (OR 0.62 [0.59-0.65]), and were less often attached to more than one agency (OR 0.83 [0.79-0.86]). Non-patient care personnel were less likely to work in rural settings (OR 0.81 [0.78-0.85])., Conclusions: EMS clinicians in non-patient care roles account for 17% of the study population. The odds of performing as a non-patient care practitioner are associated with characteristics related to demographics and workforce experience. Future work will be necessary to identify mechanisms to encourage diversity within the patient care and non-patient care workforces.

Objective: Clinical trials for patients with shock-refractory out-of-hospital cardiac arrest (OHCA), including the Amiodarone, Lidocaine or Placebo (ALPS) trial, have been unable to demonstrate definitive benefit after treatment with antiarrhythmic drugs. A Bayesian approach, combining the available evidence, may yield additional insights., Methods: We conducted a reanalysis of the ALPS trial comparing treatment with amiodarone or lidocaine with placebo in patients with OHCA following shock-refractory ventricular fibrillation or ventricular tachycardia (VF/VT). We used Bayesian regression to assess the probability of improved survival or improved neurological outcome on the 7-point modified Rankin Scale. We derived weak, moderate and strong priors from a previous clinical trial., Results: The original ALPS trial randomised 3026 adult patients with OHCA to amiodarone (n=974, survival to hospital discharge 24.4%), lidocaine, (n=993, survival 23.7%) or placebo (n=1059, survival 21.0%). In our reanalysis the probability of improved survival from amiodarone ranged from 83% (strong prior) to 95% (weak prior) compared with placebo and from 78% (strong) to 90% (weak) for lidocaine-an estimated improvement in survival of 2.9% (IQR 1.4%-3.8%) for amiodarone and 1.7% (IQR 0.84%-3.2%) for lidocaine over placebo (moderate prior). The probability of improved neurological outcome from amiodarone ranged from 96% (weak) to 99% (strong) compared with placebo and from 88% (weak) to 96% (strong) for lidocaine., Conclusions: In a Bayesian reanalysis of patients with shock-resistant VF/VT OHCA, treatment with amiodarone had high probabilities of improved survival and neurological outcome, while treatment with lidocaine had a more modest benefit., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: We sought to evaluate the utility and validity of ICU-free days and ventilator-free days as candidate outcomes for OHCA trials., Methods: We conducted a secondary analysis of the Pragmatic Airway Resuscitation Trial. We determined ICU-free (days alive and out of ICU during the first 30 days) and ventilator-free days (days alive and without mechanical ventilation). We determined ICU-free and ventilator-free day distributions and correlations with Modified Rankin Scale (MRS). We tested associations with trial interventions (laryngeal tube (LT), endotracheal intubation (ETI)) using continuous (t-test), non-parametric (Wilcoxon Rank-Sum test - WRS), count (negative binomial - NB) and survival models (Cox proportional hazards (CPH) and competing risks regression (CRR)). We conducted bootstrapped simulations to estimate statistical power., Main Results: ICU-free days was skewed; median 0 days (IQR 0, 0), survivors only 24 (18, 27). Ventilator-free days was skewed; median 0 (IQR 0, 0) days, survivors only 27 (IQR 23, 28). ICU-free and ventilator-free days correlated with MRS (Spearman's ρ = -0.95 and -0.97). LT was associated with higher ICU-free days using t-test (p = 0.001), WRS (p = 0.003), CPH (p = 0.02) and CRR (p = 0.04), but not NB (p = 0.13). LT was associated with higher ventilator-free days using t-test (p = 0.001), WRS (p = 0.001) and CRR (p = 0.03), but not NB (p = 0.13) or CPH (p = 0.13). Simulations suggested that t-test and WRS would have had the greatest power to detect the observed ICU- and ventilator-free days differences., Conclusion: ICU-free and ventilator-free days correlated with MRS and differentiated trial interventions. ICU-free and ventilator-free days may have utility in the design of OHCA trials., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Dr. Nichol is a consultant to ZOLL Circulation (San Jose, CA), Heartbeam Inc. (Santa Clara, CA), Invero Pharma LLC. (Montvale, NJ) and Orixha Inc. (Saint Cyr Au Mont d’Or, France), He has research funding from ZOLL Medical (Chelmsford, MA) and Vapotherm Inc. (Exeter, NH), Abiomed Inc. (Danvers, MA) and is a member of the steering committee of the PRINCESS 2 Trial of Ultrafast Hypothermia After Cardiac Arrest., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Purpose: To examine the hypothesis that longer distance from home-to-hospital is associated with worse outcomes among hospitalizations for community-acquired sepsis., Methods: A secondary analysis of data from the REasons for Geographic and Racial Differences in Stroke (REGARDS) prospective cohort of 30,239 white and Black US adults greater than or equal to 45 years old was conducted. Self-reported hospitalizations for serious infection between 2003 and 2012 fulfilling 2/4 systemic inflammatory response syndrome criteria were included. Estimated driving distance was derived from geocoded data and evaluated continuously and as quartiles of very close, close, far, very far (<3.1, 3.1-5.8, 5.9-11.5, and >11.5 miles respectively). The primary outcome was 30-day mortality while the secondary outcome was sequential organ failure assessment (SOFA) score on arrival., Results: Of the 912 hospitalizations for community-acquired sepsis had adequate data for analysis. The median (interquartile range) estimated driving distance was 5.8 miles (3.1,11.7), and 54 (5.9%) experienced the primary outcome. Compared to living very close, participants living very far had a mortality odds ratio of 1.30 (95% CI 0.64,2.62) and presenting SOFA score difference of 0.33 (95% CI -0.03,0.68)., Conclusions: Among a national sample of community-acquired sepsis hospitalizations, there was no significant association between home-to-hospital distance and either 30-day mortality or SOFA score on hospital presentation., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objective: Sepsis is a major public health problem. Understanding the epidemiology of sepsis subtypes is important to quantify the magnitude of the problem and identify targets for system wide treatment strategies. We sought to describe the current national epidemiology of community-acquired (CAS), hospital-acquired (HAS) and healthcare-associated sepsis (HCAS) hospitalizations among academic medical centers in the United States using current discharge diagnosis taxonomies., Methods: Retrospective analysis of patient discharge data from the Vizient Clinical Data Base/Resource Manager. We identified sepsis hospitalizations using four ICD-10 coding strategies: (1) "Martin" sepsis codes (21 ICD-10 codes), (2) "Angus" sepsis codes (ICD-10 infection + ICD-10 organ dysfunction), (3) Medicare "SEP-1" codes (28 ICD-10 codes), and (4) "explicit sepsis" codes (ICD-10 R65.20 and R65.21). Using present-on-admission flags for each diagnosis, we also distinguished: (1) community-acquired sepsis (CAS), (2) hospital-acquired sepsis (HAS), and (3) healthcare associated sepsis (HCAS)., Results: Among 22,655,240 hospitalizations, the number and incidence of sepsis hospitalizations were: (1) Martin (n = 1,718,257, 75.8 per 1000 hospitalizations), (2) Angus (n = 2,749,163, 121.3 per 1000), (3) SEP-1 (n = 1,624,909, 71.7 per 1000), and (4) explicit sepsis (n = 655,853, 28.9 per 1000). CAS was the most common sepsis subtype. HAS exhibited higher adjusted mortality than CAS. ICU admission was highest for HAS (Martin, 1.5%; Angus, 1.5%; SEP-1, 1.6%; Explicit, 1.9%)., Conclusions: These results illustrate the prevalence of sepsis at US academic medical centers using the most current sepsis classification taxonomies and discharge diagnosis codes. These results highlight important considerations when using hospital discharge data to characterize the epidemiology of sepsis., Competing Interests: The authors declare no conflicts of interests., (© 2022 The Authors. JACEP Open published by Wiley Periodicals LLC on behalf of American College of Emergency Physicians.)

Background: We sought to describe ventilation rates during out-of-hospital cardiac arrest (OHCA) resuscitation and their associations with airway management strategy and outcomes., Methods: We analyzed continuous end-tidal carbon dioxide capnography data from adult OHCA enrolled in the Pragmatic Airway Resuscitation Trial (PART). Using automated signal processing techniques, we determined continuous ventilation rates for consecutive 10-second epochs after airway insertion. We defined hypoventilation as a ventilation rate < 6 breaths/min. We defined hyperventilation as a ventilation rate > 12 breaths/min. We compared differences in total and percentage post-airway hyper- and hypoventilation between airway interventions (laryngeal tube (LT) vs. endotracheal intubation (ETI)). We also determined associations between hypo-/hyperventilation and OHCA outcomes (ROSC, 72-hour survival, hospital survival, hospital survival with favorable neurologic status)., Results: Adequate post-airway capnography were available for 1,010 (LT n = 714, ETI n = 296) of 3,004 patients. Median ventilation rates were: LT 8.0 (IQR 6.5-9.6) breaths/min, ETI 7.9 (6.5-9.7) breaths/min. Total duration and percentage of post-airway time with hypoventilation were similar between LT and ETI: median 1.8 vs. 1.7 minutes, p = 0.94; median 10.5% vs. 11.5%, p = 0.60. Total duration and percentage of post-airway time with hyperventilation were similar between LT and ETI: median 0.4 vs. 0.4 minutes, p = 0.91; median 2.1% vs. 1.9%, p = 0.99. Hypo- and hyperventilation exhibited limited associations with OHCA outcomes., Conclusion: In the PART Trial, EMS personnel delivered post-airway ventilations at rates satisfying international guidelines, with only limited hypo- or hyperventilation. Hypo- and hyperventilation durations did not differ between airway management strategy and exhibited uncertain associations with OCHA outcomes., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Background: Critically ill children may require airway management to optimize delivery of oxygen and ventilation during resuscitation. We performed a systematic review of studies comparing the use of bag-valve-mask ventilation (BVM), supraglottic airway devices (SGA), and endotracheal intubation (ETI) in pediatric patients requiring prehospital airway management., Methods: We searched Ovid MEDLINE, EMBASE, and Cochrane databases for papers that compared SGA or ETI to BVM use in children, including studies that reported survival outcomes. We followed the Preferred Reporting Items in Systematic Reviews and Meta-Analyses (PRISMA) guidelines and assessed study quality using the Newcastle-Ottawa Scale. We compared key characteristics of the candidate papers, including inclusion criteria, definitions of airway interventions, and association with outcomes., Results: Of 773 studies, eight met criteria for inclusion. Only one study was a randomized controlled trial; the other seven studies were observational. Four studies compared ETI to BVM, two studies compared SGA to BVM, one study compared ETI to SGA, and two studies compared advanced airway management (AAM) to BVM. Primary outcomes varied, ranging from overall mortality and 24-h mortality to 1-month survival, hospital survival, and neurologically favorable survival. Four of the studies found no difference in survival with the use of ETI, and four found increased mortality with the use of ETI. Associations with outcomes could not be assessed by meta-analysis due to limited number of studies and the wide variation in the design, population, interventions, and outcome measures of the included studies., Conclusions: In this systematic review, studies of prehospital pediatric airway management varied in scope, design, and conclusions. There was insufficient evidence to evaluate efficacy of pediatric prehospital airway management; however, the current research suggests that there are equal or worse outcomes with the use of ETI compared to other airway techniques. Additional clinical trials are needed to assess the merits of this practice., (© 2021 by the Society for Academic Emergency Medicine.)

Introduction: Thoracic trauma is the second leading cause of death after traumatic brain injury in children presenting with blunt chest trauma, which represents 80% of thoracic trauma in children. We hypothesized that older children undergo more clinical and surgical changes in management than younger children screened for intrathoracic injury at a single, urban, pediatric Level I trauma center., Methods: In this retrospective observational study, we determined the frequencies and types of lesions diagnosed only by chest computed tomography (CCT) and resulting changes of clinical and surgical management among different age groups in a pediatric cohort examined for blunt trauma with chest radiograph and CCT. We used logistic regression to quantify variations in CCT diagnoses and changes in clinical and surgical management across age groups. For each age category, we determined the odds ratio for diagnosis made only on CCT and subsequent changes in all clinical management and, specifically, surgical management. We performed the test of trend to determine the relationship across age with changes in management resulting from additional diagnoses made by CCT., Results: We analyzed data on 1,235 patients screened for intrathoracic injury. We found the following overall clinical management and surgical management changes, respectively, per age group: 0-2 years, 5/128 (3.9) and 0/128 (0.0); 3-6 years, 11/212 (5.2) and 1/212 (0.5); 7-10 years, 16/175 (9.1) and 2/175 (1.1); 11-13 years, 17/188 (9.0) and 3/188 (1.6); 14-17 years, 58/532 (10.9) and 25/532 (4.7). There were no observed surgical management changes in the 0-2 age group and, thus, no estimated odds ratio could be calculated. The adjusted odds ratios for the occurrence of surgical change in management (14-17 age group as reference) was 0.1 (0.0-0.9) for 3-6 years, 0.3 (0.1-1.3) for 7-10 years, and 0.3 (0.1-1.1) for 11-13 years. The trend of odds ratios across ages showed that with every subsequent year of life there was a 10% increase in management change and a 30% increase in surgical management change., Conclusion: Chest computed tomography plays a limited role in younger children and seldom significantly changes management albeit making additional diagnoses.

Background: With recent negative studies of amiodarone and lidocaine for cardiac arrest, research into other antiarrhythmics is warranted. Literature on procainamide in cardiac arrest is limited. We evaluated procainamide for out-of-hospital cardiac arrests (OHCA) from the Resuscitation Outcomes Consortium (ROC)., Methods: We included all ROC Epistry 3 OHCAs with an initial shockable rhythm that received an antiarrhythmic. We stratified cases by antiarrhythmic: procainamide, amiodarone, or lidocaine. The outcomes were prehospital return of spontaneous circulation (ROSC), ROSC in the ED, and survival to hospital discharge. We defined propensity scores based on possible confounders utilizing 1:1 propensity score matching to compare procainamide to amiodarone and lidocaine. We analyzed the matched data using logistic regression. We also used multivariable logistic regression to evaluate the association between antiarrhythmic and outcomes., Results: 3087 subjects met inclusion criteria; 51 patients received only procainamide, 1776 received amiodarone, and 1418 received lidocaine. On propensity score analysis and compared to procainamide, amiodarone had similar prehospital ROSC (OR 0.7, 95% CI 0.3-1.8), ED ROSC (OR 0.6, 95% CI 0.3-1.3), and survival (OR 1.0, 95% CI 0.3-3.1). Lidocaine also had a similar prehospital ROSC (OR 0.9, 95% CI 0.4-2.2), ED ROSC (OR 1.2, 95% CI 0.5-2.7), and survival (OR 1.4, 95% CI 0.5-4.0). However, using multivariable regression, amiodarone had lower prehospital ROSC than procainamide (aOR 0.3, 95% CI 0.1-0.6)., Conclusions: While associated with increased prehospital ROSC when compared with amiodarone using multivariable regression, procainamide otherwise had similar prehospital ROSC, ED ROSC, and survival. The role of procainamide in OHCA remains unclear., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objective: Airway management is an important priority in the care of critically ill children. We sought to provide updated estimates of the epidemiology of pediatric out-of-hospital airway management and ventilation interventions in the United States., Methods: We used data from the 2019 National Emergency Medical Services Information System (NEMSIS) data set. We performed a descriptive analysis of all patients < 18 years receiving one or more of the following: bag-valve-mask ventilation (BVM), tracheal intubation (TI), supraglottic airway (SGA) insertion, continuous positive airway pressure (CPAP), bilevel positive airway pressure (BiPAP) and surgical airway placement. We determined success and complication rates for each airway procedure., Results: Among 1,148,943 pediatric patient care encounters, airway and ventilation interventions occurred in 22,637 (1,970 per 100,000 pediatric Emergency Medical Services (EMS) activations), including 64% <11 years old, 56.1% male, 16.9% cardiac arrest, 16.6% injured, and 83.9% in urban areas. Airway interventions included: BVM 3,997 (17.7% of pediatric airway encounters), TI 3,165 (14.0%), SGA 582 (2.6%), CPAP/BiPAP 331 (1.5%) and surgical airway 29 (0.1%). TI success was 75.2% (95% CI 73.7-76.7%) and lowest for the 0-1 month age group (56.8%; 49.2-64.2%). SGA success was 88.0% (95% CI 85.1-90.6%). Vomiting was the most common airway complication (n = 223, 1%)., Conclusions: BVM and advanced airway management occur in 1 of every 51 pediatric EMS encounters. BVM is the most commonly prehospital pediatric airway management technique, followed by TI and SGA insertion. These data provide contemporary perspectives of pediatric prehospital airway management., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 Elsevier B.V. All rights reserved.)

This report summarizes the status and performance of the Journal of the American College of Emergency Physicians for 2021., (© 2022 The Authors. JACEP Open published by Wiley Periodicals LLC on behalf of American College of Emergency Physicians.)

Importance: There is clinical equipoise for COVID-19 convalescent plasma (CCP) use in patients hospitalized with COVID-19., Objective: To determine the safety and efficacy of CCP compared with placebo in hospitalized patients with COVID-19 receiving noninvasive supplemental oxygen., Design, Setting, and Participants: CONTAIN COVID-19, a randomized, double-blind, placebo-controlled trial of CCP in hospitalized adults with COVID-19, was conducted at 21 US hospitals from April 17, 2020, to March 15, 2021. The trial enrolled 941 participants who were hospitalized for 3 or less days or presented 7 or less days after symptom onset and required noninvasive oxygen supplementation., Interventions: A unit of approximately 250 mL of CCP or equivalent volume of placebo (normal saline)., Main Outcomes and Measures: The primary outcome was participant scores on the 11-point World Health Organization (WHO) Ordinal Scale for Clinical Improvement on day 14 after randomization; the secondary outcome was WHO scores determined on day 28. Subgroups were analyzed with respect to age, baseline WHO score, concomitant medications, symptom duration, CCP SARS-CoV-2 titer, baseline SARS-CoV-2 serostatus, and enrollment quarter. Outcomes were analyzed using a bayesian proportional cumulative odds model. Efficacy of CCP was defined as a cumulative adjusted odds ratio (cOR) less than 1 and a clinically meaningful effect as cOR less than 0.8., Results: Of 941 participants randomized (473 to placebo and 468 to CCP), 556 were men (59.1%); median age was 63 years (IQR, 52-73); 373 (39.6%) were Hispanic and 132 (14.0%) were non-Hispanic Black. The cOR for the primary outcome adjusted for site, baseline risk, WHO score, age, sex, and symptom duration was 0.94 (95% credible interval [CrI], 0.75-1.18) with posterior probability (P[cOR<1] = 72%); the cOR for the secondary adjusted outcome was 0.92 (95% CrI, 0.74-1.16; P[cOR<1] = 76%). Exploratory subgroup analyses suggested heterogeneity of treatment effect: at day 28, cORs were 0.72 (95% CrI, 0.46-1.13; P[cOR<1] = 93%) for participants enrolled in April-June 2020 and 0.65 (95% CrI, 0.41 to 1.02; P[cOR<1] = 97%) for those not receiving remdesivir and not receiving corticosteroids at randomization. Median CCP SARS-CoV-2 neutralizing titer used in April to June 2020 was 1:175 (IQR, 76-379). Any adverse events (excluding transfusion reactions) were reported for 39 (8.2%) placebo recipients and 44 (9.4%) CCP recipients (P = .57). Transfusion reactions occurred in 2 (0.4) placebo recipients and 8 (1.7) CCP recipients (P = .06)., Conclusions and Relevance: In this trial, CCP did not meet the prespecified primary and secondary outcomes for CCP efficacy. However, high-titer CCP may have benefited participants early in the pandemic when remdesivir and corticosteroids were not in use., Trial Registration: ClinicalTrials.gov Identifier: NCT04364737.

Emergency Medical Services personnel are often the first to intervene in the care of critically ill children. Airway management is a fundamental step in prehospital resuscitation, yet there is significant variation in current prehospital airway management practices. Our objective is to present a methodologic approach to determine the optimal strategy for prehospital pediatric airway management. We describe the conceptual premise for the Pediatric Prehospital Airway Resuscitation Trial, a novel Bayesian adaptive sequential platform trial. We developed an innovative design to enable comparison of the three predominant prehospital pediatric airway techniques (bag-mask-ventilation, supraglottic airway insertion, and endotracheal intubation) in three distinct disease groups (cardiac arrest, major trauma, and other respiratory failure). We used a Bayesian statistical approach to provide flexible modeling that can adapt based on prespecified rules according to accumulating trial data with patient enrollment continuing until stopping rules are met. The approach also allows the comparison of multiple interventions in sequence across the different disease states. This Bayesian hierarchical model will be the primary analysis method for the Pediatric Prehospital Airway Resuscitation Trial. The model integrates information across subgroups, a technique known as "borrowing" to generate accurate global and subgroup-specific estimates of treatment effects and enables comparisons of airway intervention arms within the overarching trial. We will use this Bayesian hierarchical linear model that adjusts for subgroup to estimate treatment effects within each subgroup. The model will predict a patient-centered score of 30-day intensive care unit-free survival using arm, subgroup, and emergency medical services agency as predictors. The novel approach of Pediatric Prehospital Airway Resuscitation Trial will provide a feasible method to determine the optimal strategy for prehospital pediatric airway management and may transform the design of future prehospital resuscitation trials.