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BACKGROUND There is substantial investment in layperson and first responder training involving tourniquet use for hemorrhage control. Little is known however about prehospital tourniquet application, field conversion, or outcomes in the civilian setting. We describe the experience of a metropolitan region with prehospital tourniquet application. METHODS We conducted a retrospective cohort study characterizing prehospital tourniquet use treated by emergency medical services (EMS) in King County, Washington, from January 2018 to June 2019. Emergency medical services and hospital records were abstracted for demographics, injury mechanism, tourniquet details, clinical care, and outcomes. We evaluated the incidence of tourniquet application, who applied the device (EMS, law enforcement, or layperson), and subsequent course. RESULTS A total of 168 patients received tourniquet application, an incidence of 5.1 per 100,000 person-years and 3.48 per 1,000 EMS responses for trauma. Tourniquets were applied for penetrating trauma (64%), blunt trauma (30%), and bleeding ateriovenous fistulas (7%). A subset was critically ill: 13% had systolic blood pressures of

Respiratory mechanics, such as tidal volume (VIn this prospective, pilot investigation of patients receiving prehospital advanced airway placement, paramedics applied a device to measure respiratory mechanics. We evaluated tidal volume (VOver 16-months, 7371 post-intubation breaths were measured in 54 patients, 32 patients with cardiac arrest and 22 with other conditions. Paramedics ventilated 19 patients with a small bag and 35 patients with a large bag. Overall, mean VWe observed that measuring respiratory mechanics in the prehospital setting was feasible. Tidal volumes were generally delivered within a safe range. Respiratory mechanics varied most significantly with active CPR with lower V

Background Bystander cardiopulmonary resuscitation (CPR) is a critical intervention to improve survival following out‐of‐hospital cardiac arrest. We evaluated the quality of bystander CPR and whether performance varied according to the number of bystanders or provision of telecommunicator CPR (TCPR). Methods and Results We investigated non‐traumatic out‐of‐hospital cardiac arrest occurring in a large metropolitan emergency medical system during a 6‐month period. Information about bystander care was ascertained through review of the 9‐1‐1 recordings in addition to emergency medical system and hospital records to determine bystander CPR status (none versus TCPR versus unassisted), the number of bystanders on‐scene, and CPR performance metrics of compression fraction and compression rate. Of the 428 eligible out‐of‐hospital cardiac arrest, 76.4% received bystander CPR including 43.7% unassisted CPR and 56.3% TCPR; 35.2% had one bystander, 33.3% had 2 bystanders, and 31.5% had ≥3 bystanders. Overall compression fraction was 59% with a compression rate of 88 per minute. CPR differed according to TCPR status (fraction=52%, rate=87 per minute for TCPR versus fraction=69%, rate=102 for unassisted CPR, P P Conclusions Bystander CPR quality as gauged by compression fraction and rate approached guideline goals though performance depended upon the type of CPR and number of bystanders.

Out-of-hospital cardiac arrest (OHCA) causes brain injury. Functional status of survivors at hospital discharge is a core resuscitation measure, frequently using the Cerebral Performance Category (CPC) or modified Rankin Scale (mRS). Which scale better predicts long-term survival following OHCA is not known.We evaluated long-term survival after hospital discharge in a retrospective cohort of persons resuscitated from OHCA in King County, WA from 2007 to 2015. Patients were independently assessed at discharge using both scales, leveraging the regional quality improvement registry, which records the 5-level CPC, and concurrent research studies involving the Resuscitation Outcomes Consortium, which used the 7-level mRS, taken from information in the hospital record. The risk of mortality associated with CPC and mRS categories was estimated using Kaplan-Meier survival analysis and Cox proportional hazards regression.Among 878 eligible patients discharged alive, there were 358 deaths during 9118.5 person-years of follow-up. Overall 1, 5 and 10-year survival was 84.4%, 68.5%, and 53.7% and varied according to CPC and mRS (p0.01 per Kaplan-Meier). Compared to CPC-1, hazard ratio (HR) increased incrementally for CPC-2 = 1.33 (1.03-1.73), CPC-3 = 1.90 (1.37-2.65), and CPC-4 = 8.25 (5.63-12.10). Compared to mRS = 0, HR for mRS-1 = 1.02 (0.66-1.58), mRS-2 = 1.52 (1.00-2.32), mRS-3 = 1.41 (0.92-2.14), mRS-4 = 2.00 (1.37-2.97), and mRS-5 = 4.90 (3.23-7.44).In OHCA survivors, CPC and mRS scales both predicted long-term survival. However mRS 0-1 and 2-3 groups did not have distinct prognoses, suggesting that a consolidated mRS score may simplify capture of relevant prognostic information for survival predictions.

Background: Bystander cardiopulmonary resuscitation (CPR) is a critical intervention to improve survival following out-of-hospital cardiac arrest (OHCA). We evaluated the quality of bystander CPR and whether performance varied according to the number of bystanders or provision of telecommunicator assistance (TCPR) to identify opportunities to improve care. Methods: We conducted a cohort investigation of non-traumatic cardiac arrest occurring in a large metropolitan EMS system during a 6-month period. Information about bystander care was ascertained through review of the 9-1-1 recordings in addition to EMS and hospital information to determine bystander CPR status (none vs TCPR vs unassisted), the number of bystanders on-scene, and CPR performance metrics of compression fraction and compression rate. Results: Of the 428 eligible OHCA, average age was 62.9 years (+/- 16.6), 31.5% (n=135) were female, and 76.4% (n=327) received bystander CPR. Of those receiving bystander CPR, 43.7% (n=143) received unassisted CPR and 56.3% (n=184) involved TCPR; 35.2% (N=115) had one bystander, 33.3% (N=109) had 2 bystanders, and 31.5% (n=103) had 3 or more bystanders. Overall CPR fraction was 59% with a compression rate of 88 per minute. CPR differed according to TCPR status (compression fraction=52% and rate=87 per minute for TCPR vs 69% and 102 for unassisted CPR, p=3 bystanders, test for trend p Conclusion: Overall bystander CPR quality as gauged by fraction and compression rate approached guideline goals though performance depended upon the type of CPR and number of bystanders. The findings suggest opportunities for how CPR quality and early defibrillation may be improved.

Key Points Question What is the clinical presentation to emergency medical services among persons with coronavirus disease 2019 (COVID-19)? Findings This cohort study of 124 patients with COVID-19 revealed that most patients with COVID-19 presenting to emergency medical services were older and had multiple chronic health conditions. Initial concern, symptoms, and examination findings were heterogeneous and not consistently characterized as febrile respiratory illness. Meaning The findings of this study suggest that the conventional description of febrile respiratory illness may not adequately identify COVID-19 in the prehospital emergency setting., This cohort study describes patient characteristics and prehospital presentation of patients with coronavirus disease 2019 (COVID-19) cared for by emergency medical services (EMS) in King County, Washington., Importance The ability to identify patients with coronavirus disease 2019 (COVID-19) in the prehospital emergency setting could inform strategies for infection control and use of personal protective equipment. However, little is known about the presentation of patients with COVID-19 requiring emergency care, particularly those who used 911 emergency medical services (EMS). Objective To describe patient characteristics and prehospital presentation of patients with COVID-19 cared for by EMS. Design, Setting, and Participants This retrospective cohort study included 124 patients who required 911 EMS care for COVID-19 in King County, Washington, a large metropolitan region covering 2300 square miles with 2.2 million residents in urban, suburban, and rural areas, between February 1, 2020, and March 18, 2020. Exposures COVID-19 was diagnosed by reverse transcription–polymerase chain reaction detection of severe acute respiratory syndrome coronavirus 2 from nasopharyngeal swabs. Test results were available a median (interquartile range) of 5 (3-9) days after the EMS encounter. Main Outcomes and Measures Prevalence of clinical characteristics, symptoms, examination signs, and EMS impression and care. Results Of the 775 confirmed COVID-19 cases in King County, EMS responded to 124 (16.0%), with a total of 147 unique 911 encounters. The mean (SD) age was 75.7 (13.2) years, 66 patients (53.2%) were women, 47 patients (37.9%) had 3 or more chronic health conditions, and 57 patients (46.0%) resided in a long-term care facility. Based on EMS evaluation, 43 of 147 encounters (29.3%) had no symptoms of fever, cough, or shortness of breath. Based on individual examination findings, fever, tachypnea, or hypoxia were only present in a limited portion of cases, as follows: 43 of 84 encounters (51.2%), 42 of 131 (32.1%), and 60 of 112 (53.6%), respectively. Advanced care was typically not required, although in 24 encounters (16.3%), patients received care associated with aerosol-generating procedures. As of June 1, 2020, mortality among the study cohort was 52.4% (65 patients). Conclusions and Relevance The findings of this cohort study suggest that screening based on conventional COVID-19 symptoms or corresponding examination findings of febrile respiratory illness may not possess the necessary sensitivity for early diagnostic suspicion, at least in the prehospital emergency setting. The findings have potential implications for early identification of COVID-19 and effective strategies to mitigate infectious risk during emergency care.