STEMI Destinations; Airway Types and CPR; Child Maltreatment

Transport of STEMI Patients Directly to PCI Centers
     Le May MR, Davies RF, Dionne R, et al. Comparison of early mortality of paramedic-diagnosed ST-segment elevation myocardial infarction with immediate transport to a designated primary percutaneous coronary intervention center to that of similar patients transported to the nearest hospital. Am J Cardiol 98(10):1,329-33, Nov. 15, 2006.

     Abstract: Speed of reperfusion is critical in ST-segment elevation myocardial infarction (STEMI). [Authors] assessed the safety and feasibility of an integrated metropolitan approach in which advanced-care paramedics interpret the prehospital electrocardiogram and independently refer patients with STEMI to a designated center for primary percutaneous coronary intervention (PCI). [Authors] developed and implemented a protocol in which paramedics trained in electrocardiographic interpretation bypassed the nearest emergency room and referred patients with suspected STEMI directly to a designated primary PCI center (paramedic-referred primary PCI). Outcomes of these patients were compared with those of a retrospective cohort of 225 consecutive patients with STEMI transported by ambulance to the nearest hospital emergency department. [Authors] treated 108 consecutive patients with STEMI using ambulance services according to the paramedic-referred primary PCI protocol. Primary PCI was performed in 93.5%, versus 8.9% in the control group, and the median door-to-balloon time was 63 minutes, versus 125 in the control group (p < 0.0001 for two comparisons). Thrombolytic therapy was prescribed to 80.4% of the control group, with a median door-to-needle time of 41 minutes. In-hospital mortality was 1.9% in the paramedic-referred primary PCI group versus 8.9% in the control group (p = 0.017) and remained significantly lower after statistical adjustment for baseline risk. In conclusion, paramedic-referred primary PCI is a safe and feasible strategy for treating STEMI that is associated with rapid and effective reperfusion and very low in-hospital mortality.

     Comment: It is well established that primary PCI (balloon angioplasty) to open the blocked coronary artery is the preferred treatment for STEMI, and that shortening the time interval between onset of pain (blockage of the artery) and inflating the balloon (reopening the artery) helps preserve heart muscle and improve patient outcomes. One effective way to shorten times to PCI is for EMS to identify patients with STEMIs by performing 12-lead ECGs and then transporting them directly to PCI-capable hospitals. This avoids the often-long delays in identifying the STEMI in the emergency department and arranging for a transfer to a PCI hospital. These researchers found that this resulted in a substantial decrease in time to PCI (over an hour) and reduction in mortality. This is further evidence that a regional approach using PCI-capable hospitals as STEMI receiving centers provides good care to heart attack patients. EMS systems should look at taking the lead in developing them in their communities.

Airway Types and Other CPR Tasks
     Abo BN, Hostler D, Wang HE. Does the type of out-of-hospital airway interfere with other cardiopulmonary resuscitation tasks? Resuscitation, Nov. 23, 2006 [Epub ahead of print].

     Abstract: Out-of-hospital rescuers often perform tracheal intubation (TI) prior to other cardiopulmonary resuscitation (CPR) interventions. TI is a complex and error-prone procedure that may interfere with other key resuscitation tasks. [Authors] compared the effects of TI versus esophageal tracheal Combitube (ETC) insertion on the accomplishment of other interventions during simulated cardiopulmonary resuscitation. Methods-In this prospective trial using a human simulator, two-paramedic teams simulated resuscitation of a ventricular fibrillation cardiopulmonary arrest using standard Advanced Cardiac Life Support guidelines. In each of two trials, teams used either TI or ETC as the primary airway device. Following delivery of three rescue shocks, [authors] measured time intervals to successful airway placement, intravenous (IV) line insertion, drug administration, delivery of fourth rescue shock and completion of all four tasks. [Authors] also measured the total time without chest compressions. [They] compared task completion times using non-parametric statistics (Wilcoxon signed-ranks test) with a Bonferroni-adjusted p-value of 0.008. Results-Twenty teams each completed two scenarios. Participants required a median of 172.5 seconds (IQR: 146.5-225.5) to accomplish all four tasks. Elapsed time to airway placement was significantly less for ETC than TI (median difference 26.5 seconds [IQR 13-44.5], p = 0.002). Time without chest compressions was less for ETC than TI (median difference 8.5 seconds [IQR 2.5-23.5], p = 0.005). There were no differences between ETC and TI in times to IV placement (median difference 23.5 seconds [IQR (-20)-61], p = 0.11), drug delivery (39.5 seconds [IQR (-18)-63], p = 0.07), delivery of fourth rescue shock (39.5 seconds [IQR (-21.5)-87.5], p = 0.07) or completion of all four tasks (33 seconds [IQR (-11)-74.5], p = 0.08).

     Conclusion-Compared with TI, ETC reduced time to airway placement and time without chest compressions, but did not affect elapsed times to accomplish other interventions. Additional time differences may be realized if translated to clinical out-of-hospital conditions.

     Comment: One of the most important changes in the 2005 American Heart Association CPR/emergency cardiac care guidelines was to improve the duration, depth and rate of chest compressions in order to improve the efficacy of CPR and patient survival. Numerous animal and human studies have shown that interruptions in chest compressions, even brief, will reduce circulation and worsen outcomes. Studies have also shown that the ETC is effective for ventilation. This study gives us good evidence that using an ETC can result in a more rapid placement of the airway and shorter interruption of chest compressions than inserting an endotracheal tube. Future studies should evaluate this in real patients and with other types of blind-insertion tubes.

Recognition, Management of Child Maltreatment
     Markenson D, Tunik M, Cooper A, et al. A national assessment of knowledge, attitudes and confidence of prehospital providers in the assessment and management of child maltreatment. Pediatrics 119(1):e103-8, Jan. 2007.

     Abstract: The goal was to assess the knowledge and confidence in recognition, management, documentation and reporting of child maltreatment among a representative sample of emergency medical services personnel in the United States. Methods-A questionnaire was developed and pilot-tested, with the input of experts in emergency medical services and child maltreatment, to assess knowledge, attitudes, confidence and training needs regarding assessment and treatment of child maltreatment. The questionnaire was distributed nationally to a random sample of prehospital providers by using a previously validated sampling plan. Results-Of 2,863 surveys sent to prehospital providers, 1,237 (43%) were returned. Most prehospital providers reported receiving one hour or less of continuing medical education regarding child maltreatment. Most (78%) asked for additional educational opportunities, with only 3% stating that they required no additional training. Participants lacked knowledge regarding the developmental abilities of children, management of families in which child maltreatment is suspected, key elements of the history that should be noted and the degree of suspicion necessary for reporting. Conclusions-Prehospital providers expressed confidence in their abilities to recognize and manage cases of child abuse and neglect; however, significant deficiencies were reported in several critical knowledge areas, including identification of child maltreatment, interviewing techniques and appropriate documentation.

     Comment: Child maltreatment is a major public health concern in the United States. In 2004, an estimated 872,000 children were victims of child maltreatment, with nearly 1,500 deaths. Early recognition can prevent further injury or death. Prehospital personnel can often be in the best position to suspect maltreatment. EMS systems should focus on improved training in this important subject.

Angelo Salvucci, Jr., MD, FACEP, is an emergency physician and medical director for the Santa Barbara County and Ventura County (CA) EMS Agencies, and chair of the California Commission on EMS.