OBJECTIVE: The concept of the necessity of a good quality assurance (QA) plan for emergency medical services (EMS) is well-accepted; guidelines as how best to achieve this and how current systems operate have have not been defined. The purpose of this study was to survey EMS systems to discover current methods used to perform medical control and QA and to examine whether the existence of an emergency medicine residency affected these components. METHODS: A survey was mailed in 1989 to the major teaching hospitals associated with all of the emergency medicine residency programs (n = 79) and all other hospitals with greater than 350 beds within the 50 largest United States metropolitan areas (n = 172). If no response was received, a second request was sent in 1990. The survey consisted of questions concerning four general EMS-QA categories: 1) general information; 2) prospective; 3) immediate; and 4) retrospective medical control. RESULTS: Completed surveys were received from 78.5% of residency and 50% of non-residency programs. The majority had an emergency medicine physician as medical director (80.1% vs 61.5%, p = .03). While both residency and non-residency hospitals participated in initial public and prehospital personnel education, academic programs were more likely to be involved in continuing medical education (98.2% vs 82.3%, p = .009). On-line (direct) supervision was more likely to be provided by residency institutions (96.4% vs 81.0%, p = .017) which was provided by a physician in 88.3%.(ABSTRACT TRUNCATED AT 250 WORDS)

Emergency Medical Services↗

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Combination pharmacotherapy with delayed countershock vs standard advanced cardiac life support after prolonged ventricular fibrillation.

OBJECTIVE: To test the hypothesis that combination pharmacotherapy with delayed countershock would produce higher rates of return of spontaneous circulation (ROSC) and one-hour survival when compared with standard Advanced Cardiac Life Support (ACLS) therapy. METHODS: A prospective, block-randomized, blinded, laboratory experiment was conducted in an established swine model of prolonged ventricular fibrillation (VF). Fifty-six female domestic swine were anesthetized, instrumented, and shocked into VF with a bipolar pacing catheter. The VF was untreated for 8 minutes, then basic CPR was done mechanically for 1 minute. At 9 minutes of VF, the animals were randomized to treatment with one of seven therapies: group 1, combination pharmacotherapy with epinephrine (0.20 mg/kg), lidocaine (1.0 mg/kg), bretylium (5.0 mg/kg), propranolol (1.0 mg), and U-74389G (3.0 mg/kg); group 2, epinephrine (0.20 mg/kg); group 3, lidocaine (1.0 mg/kg) and bretylium (5.0 mg/kg); group 4, propranolol (1.0 mg); group 5, U-74389G (3.0 mg/kg); group 6, normal saline solution (volume equal to that for group 1); and group 7, standard ACLS (first countershock at 9 minutes of VF). Initial countershocks for groups 1-6 were given after 11 minutes of VF. Data were analyzed with two-tailed Fisher's exact test, with alpha set at 0.05. RESULTS: Return of spontaneous circulation occurred in group 1 = 8/8 (100%); group 2 = 7/8 (88%); group 3 = 3/8 (38%); group 4 = 3/8 (38%); group 5 = 5/8 (63%); group 6 = 4/8 (50%); and group 7 = 3/8 (38%). One-hour survival occurred in group 1 = 8/8 (100%); group 2 = 5/8 (63%); group 3 = 2/8 (25%); group 4 = 2/8 (25%); group 5 = 3/8 (38%); group 6 = 2/8 (25%); and group 7 = 1/8 (13%). CONCLUSIONS: Combination pharmacotherapy with delayed countershock (group 1) produced significantly higher rates of ROSC (p = 0.03) and one-hour survival (p = 0.001) when compared with standard ACLS in this porcine model of prolonged VF.

Analysis of Variance↗

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Performance of police first responders in utilizing automated external defibrillation on victims of sudden cardiac arrest.

OBJECTIVE: Rates of resuscitation from cardiac arrest are directly tied to time to defibrillation. To maximize results, the first arriving care provider should be equipped and trained to defibrillate. This would include police in those systems where they serve this function; to date, no training program has been examined for effectiveness in this group. The purpose of this study was to evaluate a training program designed to train police first responders in the use of an automated external defibrillator (AED). METHODS: One hundred seventy police officers previously trained to the level of first responders underwent a four-hour course to teach incorporation of the AED in their practice. The evaluation of police performance was assessed by written tests prior to, immediately after, and six months post initial training. Actual field use was evaluated by using separate data collection forms filled out at the time of the resuscitation by both police and EMS providers. Each trip sheet was also reviewed. Cassette tapes from the AED were reviewed for continuous ECG tracings and audio recordings to validate and confirm the previous data. RESULTS: One hundred twenty-eight police cases were reviewed. The officers performed with few errors in AED operation, with the only problem areas being incorrect airway management and delay in performance of CPR to use the AED to reanalyze a nonshockable rhythm. These results were compared with those of the only two other studies examining the performance of first responders, which were EMTs and firefighters. The police results compared favorably with, and in some instances exceeded, those results. CONCLUSION: Police first responders trained in the use of AEDs performed at a level equivalent or superior to that in other reported studies. Future training strategies should stress proper integration of airway and CPR skills.

Automation↗

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Institution of a police automated external defibrillation program: concepts and practice.

The authors have successfully implemented automated external defibrillation (AED) training in police departments that function as first responders. The initial elements are to think the project through, and to develop clear policies and procedures for the police as they relate to dispatching so there is timeliness of notification, because response time is such a critical element. Roles for all of the participants must be clearly defined and understood by all parties for such aspects as scene management, scene responsibility of care, and transfer of care to the receiving facilities. Communication to the entire health care community that the police have an expanded role in defibrillation is desirable. A system to evaluate training, compliance with protocol, and efficacy must be developed and closely monitored. While this is a tremendous amount of work and a large time investment, the result can be a dramatic increase in patient survival.

Cardiopulmonary Resuscitation↗

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Acute hyperglycaemia impairs cognitive function in children with IDDM.

OBJECTIVE: The effects of acute hyperglycaemia on cognitive function in children remain controversial. This study was designed to investigate the suggestion that acute hyperglycaemia impairs cognition in IDDM children. DESIGN: To examine this question we studied 12 randomly selected children with IDDM (6 boys, 6 girls, mean age 12.4 years). Cognitive performance was assessed on two occasions at least six months apart (7.4 +/- 1.4 mths, range: 6.3-11.1 mths) under randomised conditions of hyperglycaemia (20-30 mmol/l) on one occasion and euglycaemia (5-10 mmol/l) on the other. Target glucose levels were achieved using a modified clamp technique with subjects and psychologist blinded to the glycaemic level. Cognitive tests chosen to assess performance skills were subtests from the Wechsler Intelligence Scale for Children-3rd Edition (WISC-111). RESULTS: No significant learning effect was present. However, there was a reduction in performance IQ at hyperglycaemia compared with euglycaemia (106 +/- 4.3 vs 112 +/- 4.5 IQ points respectively, p < 0.05). Under hyperglycaemic conditions the mean decrease in percentile score for performance IQ was 9.5%. Of the 12 children tested, 8 had a decrease in IQ when hyperglycaemic, which was independent of duration of diabetes and long term metabolic control assessed by HbA1c. CONCLUSION: Acute hyperglycaemia results in impairment of complex cognitive function in children with IDDM. This may have important implications for school performance.

Adolescent↗

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Working together. Staff at a psychogeriatric day unit found a closer working relationship with ambulancemen a valuable asset.

Explore the source record for details and available documents.

Allied Health Personnel↗

PubMedDate not supplied

Inhibition of neutrophil adhesion and the membrane attack complex of complement synergistically prolongs cardiac xenograft survival.

BACKGROUND: Hyperacute xenograft rejection is affected by activation of the complement cascade. Split products of early complement components influence the localization, activation, and effector function of platelets, granulocytes, and lymphocytes, whereas the formation of the membrane attack complex (C5b-9) leads to direct cellular injury. In a unique strain of PVG rats deficient in the C6 component of complement, the terminal membrane attack complex is not formed. However, production of the chemotactic and vasoactive components C3a and C5a proceeds normally. Guinea pig cardiac xenografts in these C6-deficient rats have prolonged survival, and at the time of rejection the inflammatory infiltrate is composed primarily of neutrophils. NPC 15669, a member of a class of antiinflammatory agents called leumedins, is known to inhibit neutrophil adhesion. The purpose of this study was to determine whether inhibition of neutrophil recruitment in animals incapable of membrane attack complex formation would prolong cardiac xenograft survival. METHODS: Cardiac xenografts from male Hartley guinea pigs were heterotopically grafted into PVG (C-) and PVG (C+) male rats. Experimental animals received 20 mg/kg of NPC 15669 i.v. before cross-clamp release and 10 mg/kg of NPC 15669 intravenously on postoperative day 1. Control animals received intravenous saline solution only. RESULTS: Complement sufficient PVG (C+) rats rejected cardiac xenografts hyperacutely despite mode of treatment: PVG (C+) rats which received saline solution (n = 5) rejected their xenografts at 10.8 +/- 2.6 minutes, and those receiving NPC 15669 (n = 5) rejected at 13.9 +/- 5.3 minutes. Histologic examination showed edema, platelet aggregation, and hemorrhage but no cellular inflammatory infiltrate. As expected, complement-deficient PVG (C-) rats had markedly longer xenograft survival in the saline solution-treated group (n = 5) with graft function being sustained 14.7 +/- 6.1 hours. NPC 15669 treatment (n = 4) further prolonged graft function to 61.0 +/- 4.7 hours. In addition to edema, platelet aggregation, and hemorrhage, histologic analysis of these grafts at the time of rejection was characterized by an infiltration of neutrophils. CONCLUSIONS: We conclude that neutrophils play a critical role in cardiac xenograft rejection when complement activation is restricted. Combined inhibition of complement and neutrophil adhesion prolongs xenograft survival longer than inhibition of either component alone.

Animals↗