Patient Care, Training, Trauma

Studies Compare Methods of Medication Administration & Patient Transport

Issue 12 and Volume 37.

IN vs. IV: Which Is Faster?
McDermott C, Collins N. Prehospital medication administration: a randomised study comparing intranasal and intravenous routes. Emerg Med Int. 2012;2012:476161. Epub 2012 Aug 16.

This Irish study involved a prospective, randomized, controlled trial measuring the speed at which 18 paramedic students could draw up and administer Narcan intranasally (IN) versus intravenously (IV) to a plastic manikin. The IN route was
91 seconds faster and considered easier by the trainees.

Research snobs may smirk at the methods in this study; after all, paramedic students working on plastic manikins isn’t going to win a Nobel prize. But keeping in mind the lack of prehospital research, it is refreshing to see simple but clinically significant research being performed within a paramedic training program. 

McDermott and Collins should be commended for one of the first studies to actually measure a time savings when Narcan is administered IN vs. IV by prehospital providers (or trainees in this case). Studies such as this one are critical to lay the groundwork so that more elaborate trials with real patients can be approved by institutional review boards. 

My guess is that starting IVs on patients who have overdosed may be even more difficult than in a plastic arm, and this time savings could be significantly more in actual field practice. Hopefully someone reading this will take the next step and repeat this study with prehospital patients.

Bottom Line
What we know: A 2012 Chicago-based study published in the journal Prehospital Emergency Care showed the feasibility of administering Narcan via nebulizer. Two studies showed therapeutic effects of Narcan were reached within eight minutes using IN and six minutes using IV, or equally rapidly if the IN dose was more concentrated.
What this study adds: This study provides experimental controlled data showing IN administration saves an average of 91 seconds compared with IV.

Transport Method to Trauma Centers
Johnson N, Carr B, Salhi R, et al. Characteristics and outcomes of injured patients presenting by private vehicle in a state trauma system. Am J Emerg Med. 2012; Sept. 20 [Epub ahead of print].

In this retrospective analysis of a statewide database, trauma patients arriving to Pennsylvania trauma centers by private vehicle (PV) were less likely to die than those arriving by EMS. This large sample included more than 90,000 patient records over five years (2003–2007), of which 10% arrived by PV. The patients arriving by EMS were more severely injured, but even after the authors adjusted their calculations to account for injury severity, being transported via PV was associated with
less mortality.

At first glance this study caused me to cringe. After all, why have EMS if people are better off driving themselves to
the hospital? 

It’s important to remember that an association does not determine cause and effect. As is the case with most studies, it’s critical in this case to read the entire paper before jumping to any “tabloid” conclusions from a headline. To understand the full message of this study we must consider the author’s own discussion comments. Besides the usual limitations with retrospective analyses of large databases, the authors point to a lack of critical information that we already know affects outcomes: Length of prehospital time was not available for more of the PV records, and adjustments to the severity score analysis may not account for the real severity of the patients. This makes is very difficult to draw meaningful conclusions from this study. 

One fascinating and counter-intuitive finding is that patients transported by ALS had shorter overall prehospital times, even though BLS had a larger percentage of the urban responses. Traditional thought has been that paramedics stay-and-play
more often than EMTs, and that ALS care is more prevalent in urban environments.

These data seem to contradict both of these popular thoughts. The authors postulate that more advanced assessment may lead to earlier recognition of potentially sick patients. It’s my hope that reviewing this Pennsylvania study will irritate readers and act as a catalyst for more prospective and purposeful research. lactate meters and temporal artery thermometers by paramedics to aid in the out-of-hospital recognition of sepsis: A pilot study. Ann Emerg Med. 2012;60(4):S43.

Watch Box

Note: This study was generated out of Allina Health EMS and the author of this column claims a conflict of interest. Readers are advised to read the abstract for themselves.Watch BoxStay tuned for more on a project by Hokanson and co-authors that was presented at the 2012 American College of Emergency Physician (ACEP) meeting. Over a nine-month period, 35 paramedics used temporal artery thermometers (TAT) and early lactate kits to identify sepsis patients who might benefit from early goal-directed therapy.

The prehospital rapid lactate readings correlated well to the in-hospital readings. But the hospitals took an average of 67 minutes to gain venous access and 116 minutes to get a lactate reading. This leads the authors to conclude that trained paramedics may be able to alert for, and begin, goal-directed sepsis therapy two hours sooner than current in-hospital times.