Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors
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To determine survival in pediatric trauma patients receiving cardiopulmonary resuscitation (CPR) in the prehospital setting and to identify subgroups of patients who may have increased survival rates. ⋯ Survival of pediatric trauma patients after receiving CPR in the prehospital setting is significantly higher than expected in adult patients. Penetrating trauma, the need for additional CPR at the trauma center, and prehospital intubation are all predictors of a worse outcome.
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Awareness of the health and financial repercussions of unnecessary immobilization has made cervical spinal immobilization controversial in out-of-hospital care. Clinical criteria for clearance of the cervical spine in the hospital based on mechanism of injury have been supported by many trauma centers. However, implementation of clinical criteria for cervical spinal clearance in out-of-hospital settings is not as well validated by multicenter studies or accepted by many emergency departments. This consensus group recommends that clinical criteria to determine "low-risk" patients be available for use by emergency medical services providers in out-of-hospital settings; however, training, audits, quality management, integration into the medical community, and extent of program implementation should be decided based on individual emergency medical services systems.
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Airway management and optimal ventilation are crucial aspects of managing out-of-hospital medical emergencies. The goals in these situations are controlled ventilation and optimized inspiratory time, expiratory time, and airflow. Numerous techniques and devices are available to deliver oxygen-enriched air to patients during resuscitation. ⋯ These devices should be available on every ambulance, and the ability to use ETVs should be part of each EMS provider's skill set. Furthermore, all patients requiring emergency ventilation must be adequately monitored, including continuous monitoring of end-tidal carbon dioxide concentrations. As with any other skill, ventilation requires attention during initial training, continuing education and skill reinforcement, and quality review.
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The complete and irreversible cessation of life is often difficult to determine with complete confidence in the dynamic environment of out-of-hospital emergency care. As a result, resuscitation efforts often are initiated and maintained by emergency medical services (EMS) providers in many hopeless situations. Medical guidelines are reviewed here to aid EMS organizations with respect to decisions about: 1) initiating or waiving resuscitation efforts; 2) the appropriate duration of resuscitation efforts; and 3) recommended procedures for on-scene or prehospital pronouncement of death (termination of resuscitation). ⋯ Regardless of the medical futility criteria, specialized training of EMS providers and targeted related testing of operational issues need to precede field implementation of on-scene pronouncement policies. Such policies also must be modified and adapted for local issues and resources. In addition, although the current determinations of medical futility, as delineated here, are important to establish for societal needs, the individual patient's right to live must be kept in mind always as new medical advances are developed.