Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors
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The most appropriate prehospital approach to resuscitative fluid interventions for trauma patients involves: determining the mechanism of injury (i.e., blunt versus penetrating versus thermal injury); identifying anatomic involvement (i.e., truncal versus isolated head injury versus isolated extremity injury); and staging the condition (i.e., hemodynamic stability versus instability versus moribund state). Based on available data, the liberal use of fluid infusions for presumed uncontrolled internal hemorrhage, such as that usually occurring after penetrating abdominal and thoracic injuries, is no longer advised. Although some infusion might be appropriate in patients with extremely severe hemorrhage (i.e., no palpable blood pressure, unconscious), the priority in such patients is rapid evacuation to definitive surgical intervention, with airway control and intravenous access provided en route. ⋯ However, the addition of potential intra-abdominal, intrapelvic, or intrathoracic injuries with uncontrolled hemorrhage confounds the decision-making process. Although conventional wisdom has been to provide aggressive blood pressure support under these circumstances through judicious use of isotonic, or perhaps hypertonic, fluid resuscitation, recent experimental data challenge even this philosophy. Use of new blood substitutes might help to resolve some of these issues by providing oxygen delivery with limited volume in the face of uncontrolled hemorrhage.
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Errors in health care can have serious consequences, not only for patients but for society as a whole, given the considerable national expenditures required to address these errors. Because of the number of patients treated and the acuity of emergency situations, eliminating errors should be a priority in emergency medical services (EMS) systems. In a recent report, the Institute of Medicine called for improvements in patient safety, which it defined as freedom from accidental injury. ⋯ Unfortunately, addressing the problem of medical errors in EMS systems still suffers from a paucity of data, owing to a lack of organized, funded programs backed by legislation and dedicated government coordination. We recommend that EMS medical directors consider specific error audits to decrease sources of errors and to be better able to identify EMS providers who would benefit from retraining. Error audits might first be focused on the following potentially serious errors: equipment malfunction, failure to check oxygen saturation, failure to immobilize the patient, use of incorrect protocol or algorithm, failure to check glucose levels, failure to recognize patient deterioration, failure to detect misplaced endotracheal tubes, and use of wrong drug or drug dose.
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On October 5, 2000, the select Consensus Panel on Mental Health Needs for Providers of Emergency Medical Services for Children (EMSC) was convened in Washington, DC, by the American Psychological Association. This paper reports the results of that two-day meeting. ⋯ The panel recommended the proliferation of state-of-the-art information to settings that provide EMSC in order to assist in the implementation of acute psychological support services to assist EMSC providers as well as the pediatric patients and their families. The Critical Incident Stress Management (CISM) crisis intervention program was viewed as one such system of psychological support services that should be pursued.
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Since the early 1970s, various publications and legislation have contributed to the development of emergency medical services (EMS) information systems and databases. Yet, even today, EMS systems vary in their ability to collect patient and systems data and to put these data to use. ⋯ For this reason, the National Association of State EMS Directors is working with its federal partners at the National Highway Traffic Safety Administration (NHTSA) and the Trauma and EMS program of the Health Resources and Services Administration's (HRSA's) Maternal and Child Health Bureau to develop a national EMS database. Such a database would be useful in developing nationwide EMS training curricula, evaluating patient and EMS system outcomes, facilitating research efforts, determining national fee schedules and reimbursement rates, and providing valuable information on other issues related to EMS care.
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Comparative Study
Regional EMS experience with etomidate for facilitated intubation.
To report the preliminary experience of the Central New York emergency medical services (EMS) region with etomidate for prehospital facilitated intubation. ⋯ Preliminary data suggest increased rates of success for facilitated intubation using etomidate, when compared with diazepam, with most intubations successful on the first attempt. Limitations of this study include a small sample size and self-reporting of airway data by paramedics.