- Email: [email protected]
Or Chest Pain
Research Forum Abstracts motor vehicle crash (MVC) severity and the potential for serious injury when viewing crash scene photographs. Methods: Design: Cross-sectional survey. Setting: Denver Health Medical Center (DHMC) and the Denver Health Paramedic Division (DHPD) in Denver, Colorado. DHMC is a level 1 trauma center and the DHPD serves as the primary EMS system for Denver County. Population: Attending and resident emergency physicians, paramedics, and emergency medical technicians (EMTs). Survey Design: 100 crash scene photographs were identified to represent a broad range of mechanism and severity as determined by consensus expert opinion. Survey Administration: A Web-based survey platform was used and respondents viewed all photographs and were asked to rate the severity of the crash on a 10-point Likert scale (Crash Score) and the potential for serious injury on an 11-point 0% - 100% scale (Injury Score). Serious injury was defined as skull fracture or intracranial bleeding, spine fracture or spinal cord injury, intrathoracic or intraabdominal injury or long bone fracture. The MVC victim was assumed to be an otherwise-healthy restrained driver in the car pictured. Analyses: Crash and Injury Scores were stratified into emergency physicians and paramedic/EMT (EMS) groups and their means were calculated for each photo. Spearman rank correlation coefficients with 95% confidence intervals (95%CI) were then calculated to assess correlation between the two study groups. Secondary analyses were performed after categorizing data into quartiles based on participants’ estimations of MVC severity. Results: A total of 54 attending and 53 resident emergency physicians, 156 paramedics, and 34 EMTs were invited to participate in the survey. Of these, 39 (72%) attending and 46 (87%) resident emergency physicians, 107 (69%) paramedics, and 17 (50%) EMTs completed the survey. Of these, 183 (88%) surveys were completed in full. The overall Crash Score correlation coefficient between emergency physicians and EMS was 0.98 (95% CI, 0.97- 0.99). The Crash Score correlation coefficients for each quartile were 0.86 (0.57 - 0.97), 0.93 (0.85 - 0.96), 0.58 (0.16 - 0.85) and 0.88 (0.66 - 0.97), respectively. The overall Injury Score correlation coefficient between emergency physicians and EMS was 0.98 (0.88- 0.97). The Injury Score correlation coefficients for each quartile were 0.94 (0.48 - 0.91), 0.76 (0.50 - 0.92), 0.80 (0.69 - 1.00) and 0.94 (0.57 - 0.97), respectively. Conclusion: Although overall agreement between emergency physicians and EMS personnel was excellent, substantial differences in estimation of crash and potential for injury severity were identified among crashes estimated to be moderate in severity.
212
Utility of Diagnostic Tests Performed on Pediatric Patients Presenting to an Emergency Department With Syncope And/Or Chest Pain
Sachdev M, Rao RE, Olympia RP/Hershey Medical Center, Hershey, PA
Study Objectives: To determine the clinical utility of diagnostic tests, specifically the electrocardiogram (EKG) and chest radiograph (CXR), in the workup of pediatric patients presenting to an emergency department (ED) with syncope and/or chest pain. Methods: A retrospective chart review was performed on 413 pediatric patients between the ages of 2 and 18 years presenting to a Level 1 trauma center ED in Central Pennsylvania with syncope and/or chest pain between July 2008 and June 2009. Data obtained from 273 patients who met inclusion criteria were used in the analysis. Data obtained from patients who were previously diagnosed with a congenital or acquired cardiac disease or seizures, who sustained recent chest trauma, who were currently pregnant, or recently diagnosed with pneumonia were excluded from analysis. Results: Of the 273 patients (mean age⫽13.9 years; 60% females] who met inclusion criteria, an EKG was performed on 200 patients (73%), of which 5 (2.5% [95%CI: 0-5%]) had positive findings. A CXR was performed on 130 patients (48%), of which 5 (3.8% [95%CI: 1-7%]) had positive findings. 5 patients had positive EKG findings interpreted by the ED physician as questionable ventricular hypertrophy (1), QT-prolongation (2), and S-T changes in multiple leads (2). Of these, 4 presented with syncope and one with chest pain. One patient was hospitalized, and the remaining were discharged from the ED with recommendations to follow-up with pediatric cardiology as an outpatient. Follow-up cardiology data was available for 3 of the 5 patients. These patients were determined by the pediatric cardiologist to have a non-cardiac etiology to explain the original symptoms that brought them to the ED, and no further followup was suggested. Furthermore, the one patient hospitalized with EKG findings concerning for questionable ventricular hypertrophy was determined to have noncardiac etiology to explain the original symptoms. Of the patients with a positive CXR, all 5 presented with prodromal symptoms (fever and upper respiratory type symptoms) and had CXR findings consistent with pneumonia. All 5 were discharged to home with appropriate outpatient follow-up.
S70 Annals of Emergency Medicine
Conclusion: Although the vast majority of pediatric patients presenting to the ED with chest pain and/or syncope are subject to EKG and CXR, the utility of these diagnostics has not been well established. Preliminary data from our study suggest that EKG and CXR are often normal and may provide minimal utility in the workup and disposition of these patients.
213
The Use of the Airtraq Device by Paramedics Improves First Attempt Success Rate as Compared to Direct Laryngoscopy In the Out-of-Hospital Setting
Harvey A, Vivier S, Henderson R, Slattery D, Selitzky S, Stepaniuk P, Rogers B/ City of Henderson Fire Department, Henderson, NV; University of Nevada School of Medicine, Las Vegas, NV
Study Objectives: We test the hypothesis that paramedic first pass succes proportions are higher utilizing the Airtraq device versus Direct Laryngoscopy (DL) performed in the out-of-hospital setting. Methods: Prospective observational, non-industry-sponsored study. Suburban fire-based all ALS EMS system serving a population of 200,000 where paramedics with more than one year of experience were given standardized training on the use of the Airtraq device using lecture and a Laerdal SimMan Manikin. Competency was verified prior to deployment of the Airtraq device. Inclusion criteria: Adult DL or Airtraq intubation during the study period. Exclusion criteria: Combitube or noninvasive airway management. Choice of technique was based on paramedic discretion and not dictated by protocol or the study. A waiver of informed consent was granted from our institutional review board. Attempts were consistant with the National Association of EMS Physicians (NAEMSP) Recommended Guidelines for Uniform Reporting of Data from Out-of-hospital Airway Management defined as insertion of the laryngoscope blade or the Airtraq device was inserted. Tracheal placement was was verified by waveform capnometry. Paramedics completed a detailed data collection form modeled after the complete (NAEMSP) Recommended Guidelines for Uniform Reporting of Data from Out-of-hospital Airway Management on all patients with attempted intubation. Data were entered into a database and analyzed using SPSS for windows, version 16.0 (SPSS Inc. Chicago, IL). Our primary outcome measure was first pass success proportion and our secondary outcome measures were the proportion of Cormack and Lehane grade 1 airways. We report descriptive statistics and 95 % CI as appropriate and utilized chi square for comparison of proportions. Results: In a 9-month period 238 patients met inclusion criteria. Results are presented as [%, (95% CI)]. Sixty-seven (28%, (23,34) were attempted using the Airtraq and 171 (72%, (66,77) patients attempts were by DL as the first attempt method. No statistical significants was detected between groups in age or the presence of trauma, c-spine, induction or CPR during intubation (p⬎0.05). Airtraq first pass success proportion was 51 (76% (64,86) versus DL 99 (58% CI 65%-50%) Chisquare (x2 ⫽6.1)(p⫽0.0135). Grade 1 view for Airtraq was reported 51 (76%(64,86) versus DL 38 (22%, (16,29) Chi-square (x2 ⫽57.45)(p⬍.0001). Limitations: Not randomized, small sample size. Conclusion: In our cohort, the Airtraq demonstraed better first attempt success rates than DL when used by paramedics in the out-of-hospital setting. Airtraq use resulted in a higher porportion of grade 1 views.
214
EMS Out-of-Hospital Time and Its Association With Mortality In Trauma Patients Presenting to an Urban Level I Trauma Center
McCoy CE, Kahn C, Menchine M, Sampson S, Anderson C/University of California, Irvine, Orange, CA
Study Objective: To determine the association between emergency medical services (EMS) out-of-hospital times and mortality in trauma patients presenting to an urban level I trauma center. Methods: We conducted a secondary analysis of a prospective cohort registry of trauma patients presenting to a level I trauma center over a 13-year period (19962009). Inclusion criteria were patients sustaining traumatic injury who presented to an urban level I trauma center. Exclusion criteria were extrication, missing or erroneous out-of-hospital times, and intervals exceeding five hours. The primary outcome was inhospital mortality. EMS out-of-hospital intervals (scene time and transport time) were evaluated using multivariate logistic regression.
Volume , . : September
212
Utility of Diagnostic Tests Performed on Pediatric Patients Presenting to an Emergency Department With Syncope And/Or Chest Pain
Sachdev M, Rao RE, Olympia RP/Hershey Medical Center, Hershey, PA
Study Objectives: To determine the clinical utility of diagnostic tests, specifically the electrocardiogram (EKG) and chest radiograph (CXR), in the workup of pediatric patients presenting to an emergency department (ED) with syncope and/or chest pain. Methods: A retrospective chart review was performed on 413 pediatric patients between the ages of 2 and 18 years presenting to a Level 1 trauma center ED in Central Pennsylvania with syncope and/or chest pain between July 2008 and June 2009. Data obtained from 273 patients who met inclusion criteria were used in the analysis. Data obtained from patients who were previously diagnosed with a congenital or acquired cardiac disease or seizures, who sustained recent chest trauma, who were currently pregnant, or recently diagnosed with pneumonia were excluded from analysis. Results: Of the 273 patients (mean age⫽13.9 years; 60% females] who met inclusion criteria, an EKG was performed on 200 patients (73%), of which 5 (2.5% [95%CI: 0-5%]) had positive findings. A CXR was performed on 130 patients (48%), of which 5 (3.8% [95%CI: 1-7%]) had positive findings. 5 patients had positive EKG findings interpreted by the ED physician as questionable ventricular hypertrophy (1), QT-prolongation (2), and S-T changes in multiple leads (2). Of these, 4 presented with syncope and one with chest pain. One patient was hospitalized, and the remaining were discharged from the ED with recommendations to follow-up with pediatric cardiology as an outpatient. Follow-up cardiology data was available for 3 of the 5 patients. These patients were determined by the pediatric cardiologist to have a non-cardiac etiology to explain the original symptoms that brought them to the ED, and no further followup was suggested. Furthermore, the one patient hospitalized with EKG findings concerning for questionable ventricular hypertrophy was determined to have noncardiac etiology to explain the original symptoms. Of the patients with a positive CXR, all 5 presented with prodromal symptoms (fever and upper respiratory type symptoms) and had CXR findings consistent with pneumonia. All 5 were discharged to home with appropriate outpatient follow-up.
S70 Annals of Emergency Medicine
Conclusion: Although the vast majority of pediatric patients presenting to the ED with chest pain and/or syncope are subject to EKG and CXR, the utility of these diagnostics has not been well established. Preliminary data from our study suggest that EKG and CXR are often normal and may provide minimal utility in the workup and disposition of these patients.
213
The Use of the Airtraq Device by Paramedics Improves First Attempt Success Rate as Compared to Direct Laryngoscopy In the Out-of-Hospital Setting
Harvey A, Vivier S, Henderson R, Slattery D, Selitzky S, Stepaniuk P, Rogers B/ City of Henderson Fire Department, Henderson, NV; University of Nevada School of Medicine, Las Vegas, NV
Study Objectives: We test the hypothesis that paramedic first pass succes proportions are higher utilizing the Airtraq device versus Direct Laryngoscopy (DL) performed in the out-of-hospital setting. Methods: Prospective observational, non-industry-sponsored study. Suburban fire-based all ALS EMS system serving a population of 200,000 where paramedics with more than one year of experience were given standardized training on the use of the Airtraq device using lecture and a Laerdal SimMan Manikin. Competency was verified prior to deployment of the Airtraq device. Inclusion criteria: Adult DL or Airtraq intubation during the study period. Exclusion criteria: Combitube or noninvasive airway management. Choice of technique was based on paramedic discretion and not dictated by protocol or the study. A waiver of informed consent was granted from our institutional review board. Attempts were consistant with the National Association of EMS Physicians (NAEMSP) Recommended Guidelines for Uniform Reporting of Data from Out-of-hospital Airway Management defined as insertion of the laryngoscope blade or the Airtraq device was inserted. Tracheal placement was was verified by waveform capnometry. Paramedics completed a detailed data collection form modeled after the complete (NAEMSP) Recommended Guidelines for Uniform Reporting of Data from Out-of-hospital Airway Management on all patients with attempted intubation. Data were entered into a database and analyzed using SPSS for windows, version 16.0 (SPSS Inc. Chicago, IL). Our primary outcome measure was first pass success proportion and our secondary outcome measures were the proportion of Cormack and Lehane grade 1 airways. We report descriptive statistics and 95 % CI as appropriate and utilized chi square for comparison of proportions. Results: In a 9-month period 238 patients met inclusion criteria. Results are presented as [%, (95% CI)]. Sixty-seven (28%, (23,34) were attempted using the Airtraq and 171 (72%, (66,77) patients attempts were by DL as the first attempt method. No statistical significants was detected between groups in age or the presence of trauma, c-spine, induction or CPR during intubation (p⬎0.05). Airtraq first pass success proportion was 51 (76% (64,86) versus DL 99 (58% CI 65%-50%) Chisquare (x2 ⫽6.1)(p⫽0.0135). Grade 1 view for Airtraq was reported 51 (76%(64,86) versus DL 38 (22%, (16,29) Chi-square (x2 ⫽57.45)(p⬍.0001). Limitations: Not randomized, small sample size. Conclusion: In our cohort, the Airtraq demonstraed better first attempt success rates than DL when used by paramedics in the out-of-hospital setting. Airtraq use resulted in a higher porportion of grade 1 views.
214
EMS Out-of-Hospital Time and Its Association With Mortality In Trauma Patients Presenting to an Urban Level I Trauma Center
McCoy CE, Kahn C, Menchine M, Sampson S, Anderson C/University of California, Irvine, Orange, CA
Study Objective: To determine the association between emergency medical services (EMS) out-of-hospital times and mortality in trauma patients presenting to an urban level I trauma center. Methods: We conducted a secondary analysis of a prospective cohort registry of trauma patients presenting to a level I trauma center over a 13-year period (19962009). Inclusion criteria were patients sustaining traumatic injury who presented to an urban level I trauma center. Exclusion criteria were extrication, missing or erroneous out-of-hospital times, and intervals exceeding five hours. The primary outcome was inhospital mortality. EMS out-of-hospital intervals (scene time and transport time) were evaluated using multivariate logistic regression.
Volume , . : September