Vol. 5.7
1. Prehospital Considerations for Mass-Shooting Incidents. Levy MJ, Eastman AL, Epley E, Schweit KW, Slattery DE, Cannon JW. J Am Coll Surg, 2023;236:269-272.
2. Time to Antiarrhythmic and Association with Return of Spontaneous Circulation in the United States. Huebinger R, Chan HK, Bobrow B, et al. Prehosp Emerg Care, 2023;27:177-183.
3. Are Pelvic Binders an Effective Prehospital Intervention? Bangura A, Burke CE, Enobun B, et al. Prehosp Emerg Care, 2023;27:24-30
4. Differences in Out-of-Hospital Cardiac Arrest Management and Outcomes across Urban, Suburban, and Rural Settings. Peters GA, Ordoobadi AJ, Panchal AR, Cash RE. Prehosp Emerg Care, 2023;27:162–169.
International Prehospital Medicine Institute Literature Review, February 2023
1. Prehospital Considerations for Mass-Shooting Incidents. Levy MJ, Eastman AL, Epley E, Schweit KW, Slattery DE, Cannon JW. J Am Coll Surg, 2023;236:269-272.
In an effort to improve the medical response to mass-shooting incidents, Goolsby et al. published a paper titled “Mass shootings in America: consensus recommendations for healthcare response” in the January 2023 issue of the Journal of the American College of Surgeons. In that paper, 8 universal consensus recommendations were made including:
- Readiness training
- Public education
- Triage
- Communication
- Patient tracking
- Medical records
- Family reunification
- Mental health services
In this paper, the authors sought to focus the recommendations specifically on the prehospital response to these events. The recommendations were grouped into 3 categories: pre-mass shooting, during a mass shooting, and post-mass shooting, to help organize the EMS approach.
Pre-Mass Shooting: Specifically, they call for “communities to engage in regular MSI focused readiness efforts that include lessons learned from other MSI events”. Flexible and adaptable plans need to be developed with clear operational objectives including roles and objectives. Clear agreement on unified incident command structure must be achieved with all entities (Police, Fire, EMS, Medical direction, EMS Physicians and Trauma surgeons) having appropriate input and oversight. Response teams that consist of “specially trained EMS and law enforcement personnel capable of making entry into high-threat areas” should be identified. Potential casualty collection points should be selected to optimize patient movement by assessing geographic and logistical aspects of the response environments.
Once these plans are in place, MSI training should be conducted utilizing the full spectrum of available training exercise modalities including high-fidelity simulations to table top exercises. The training needs to consider a variety of targets in varying complexities incorporating participation by multiple levels of government response including local, country, state and federal. A formal mass-casualty triage system should be selected and trained on prior to be called on to be utilized. Response and evacuations routes should be pre-planned and worked into the plans including the police response training to set up the ingress and egress security including consideration of rapid police transport. Communities should work together in order to “leverage fire/rescue/EMS assets to augment hospital personnel after large MSI’s.”
Community outreach programs to include “Stop the Bleed” training and to support distribution of the required supplies to control bleeding throughout the community with programs to ensure people know where to find these supplies. Planning for family re-unification involves training and coordination through local state and county services, the Department of Justice Office of Victims of Crimes and the FBI’s Victim services Division.
During a Mass Shooting: The EMS environment during a mass-shooting incidentincludes both medical and tactical concerns. These events call for all responders to maintain a high degree of situational awareness regarding ongoing and additional threats. Those not involved in the tactical response should be rendering care during initial triage. Additional resources should be requested early and these resources should be staged through the unified command logistical structure. Public safety agencies must also prepare for, identify and deal with self-deploying responders.
Self-presenting casualties can arrive throughout the incident and responders and healthcare facilities should be prepared for their arrival. Law enforcement will be called upon to protect the influx of patients while keeping uninjured people away and at the same time watching for perpetrators who may remain at large.
Post-Mass Shooting: Staffing surge plans for the entire array of engaged agencies and facilities should be implemented including for hospitals, police, fire, rescue, and EMS agencies. This will ensure adequate rest and support. After action reviews should be conducted as soon as possible after the event along with additional reviews later after the event. Lastly, arrangements should be made to offer mental health services and counseling on an as-needed basis.
This paper provides an overview of important aspects of public safety preparedness and planning for a mass-shooting incident. Working together with everyone in the community will lead to better preparation when called to respond to a mass-shooting incident.
2. Time to Antiarrhythmic and Association with Return of Spontaneous Circulation in the United States. Huebinger R, Chan HK, Bobrow B, et al. Prehosp Emerg Care, 2023;27:177-183.
In the United States, 350,000 people sustain an out-of-hospital cardiac arrest annually. Survival rate is higher for patients that present to EMS in pulseless ventricular tachycardia (p-VT) or ventricular fibrillation (VF). The American Heart Association’s Advanced Cardiac Life Support (ACLS) algorithm for p-VT and VF call for the administration of an antiarrhythmic medication after two unsuccessful defibrillations and three, two-minute rounds of uninterrupted CPR. The two antiarrhythmic medications recommended are amiodarone and lidocaine. Administration routes of these two medications can be either intravenous (IV) or intraosseous (IO). Additionally, the ACLS algorithm calls for epinephrine to be given every three to five minutes for the duration of the cardiac arrest.
The authors of this paper examined the relationship between time of antiarrhythmic administration and return of spontaneous circulation (ROSC). This study was a University of Texas Health Science Center IRB approved retrospective study of data from the National EMS Information System (NEMSIS) for the date range of 2018 through 2019. A total of 20,624 cardiac arrests with a shockable rhythm were identified. Of these, 10,563 patients were included in the study. Excluded cases had missing data or times. Most of the patients were males (67.9%) with a mean age of 64. Slightly over 70% of cases were witnessed and two-thirds occurred at home.
Amiodarone was administered to 88% of patients and lidocaine was given to 12%. The median time to receive an antiarrhythmic after EMS arrival was 13 minutes (19 minutes after the 911 call was made). Overall, 95% of patients received an antiarrhythmic within 30 minutes of EMS arrival (almost 40 minutes post 911 call). When ROSC occurred, it happened when the antiarrhythmic was given sooner than later in the arrest. While fewer patients received lidocaine as the antiarrhythmic, those that did had a higher incidence of ROSC (30.2% for lidocaine and 24.5% for amiodarone).
The authors acknowledged a number of limitations to this study. All data was self-reported by the provider. Times are not always documented in “real time” and are instead reported as the best memory of the reporter. Bystander CPR could not be evaluated as it was not reported in NEMSIS at the time of this study. ACLS guidelines do not have a preference for the route of administration of antiarrhythmic drugs. Medications could have been administered either by IV or IO. Epinephrine is also part of the ACLS p-VT and VF algorithm. There was no consideration as whether or not epinephrine was given, by what route or at what time. The long-standing question of the value of an advanced airway in cardiac arrest was not considered either. Finally, experience levels of the providers was not considered.
ACLS algorithms are updated every few years. The collaborators that write these recommendations need data to determine the best treatment for an emergency that affects 350,000 patients annually in the United States. Studies such as this help to provide that important data. It makes sense that the sooner a patient in extremis receives a medication (or other intervention such as CPR or defibrillation) the better the chances for survival. Providers should be conscious of the need for speed and efficiency of treatment when caring for out of hospital cardiac arrest.
3. Are Pelvic Binders an Effective Prehospital Intervention? Bangura A, Burke CE, Enobun B, et al. Prehosp Emerg Care, 2023;27:24-30
Severe injuries of the pelvic ring that cause displacement of bone fragments may also produce profound bleeding, particularly in the case of open-book fractures. External pelvic binders have been used in the hospital environment until surgical intervention and fixation can take place. The use of pelvic binders by military field EMS personnel was adopted during the war on terror, necessitated by the injuries encountered by soldiers wounded by IEDs. The commercial pelvic binder has slowly found its way into the civilian EMS community in many areas. The authors of this study examined the prehospital implementation and use of pelvic binders and secondarily their effects on the early management of hypovolemia.
The authors conducted a retrospective single-center cohort study of unstable pelvic ring fractures identified from reviewing data obtained from January 2011 to December 2020. Classification of unstable pelvic ring fracture was done using the accepted Young and Burgess Classification system. Inclusion in the study required the application of a pelvic binder to a classified unstable pelvic ring injury either in the prehospital environment or in the emergency department caused by blunt or blast injuries, transport to the primary study center, and availability of EMS charts. Pelvic binders are not a mandated device for EMS in the study state, however EMS agencies can employ them. Pelvic binding in this study was defined as the application of a commercial binder or wrapping with a sheet.
During the study period, 1,527 patients were identified with pelvic ring factures. Of this group 12,365 were excluded due to non-qualifying pelvic factures (n=1,187), inter-hospital transfers (n=66), and no pelvic binder applied (n=54). A total of 162 pelvic ring fractures were analyzed with 52 having a pelvic binder applied in the prehospital phase and 110 applied in the hospital. EMS providers suspected an unstable pelvic fracture in 85 cases and applied a pelvic compression device in 52 patients (61%). After adjusting for severity, there was no statistical difference in patient outcomes, with the exception of a shorter hospital stay in those patients who had a pelvic binder applied in the field (15.5 days vs 21.0 days respectively). There was no difference in early vital signs, RBC administered in the first 24 hours and most importantly mortality. Interestingly, the authors noted that patients with a lower injury severity score (ISS) were more likely to have a pelvic binder applied. While the lower ISS may account for the shorter hospital stay, the authors were not able to identify any other factors that would support the lower hospital stay. Of note, patients that had a pelvic compression device placed had a longer total prehospital time interval than those that did not (63 mins vs 55 mins respectively).
The retrospective nature of this study leads to some of the limitations. The study was conducted across a period of 11 years. During this period both prehospital and emergency department trauma and transfusion resuscitation has changed. Secondary the use of pelvic binders in the geographical study area varied across jurisdictions with different protocols for the application of pelvic binding. The type of binding, commercial binder versus sheet, could not be determined although the authors state that commercial binders are common in the EMS systems studied. Lastly, the study population was small and may not have been adequate to detect a difference in outcomes.
The authors hoped to show that the application of a pelvic binder in the prehospital setting would improve outcome, however, only a third of the patients with an unstable pelvic fracture received a pelvic binder in the field and no differences in patient outcome were found. The study also demonstrated that more severely injured patients did not have a pelvic binder applied. While this on the surface would seem counter-intuitive, more severely injured patients require greater primary interventions than isolated pelvic ring fractures which could lead to the intervention of pelvic binding talking a lower priority during the short transport time in urban EMS settings. As the authors pointed out, the study did not demonstrate any outcome benefits with the exception of an unexplained shortened hospital stay. Further multi-center studies are needed to determine the efficacy or harm of pelvic binding by prehospital providers.
4. Differences in Out-of-Hospital Cardiac Arrest Management and Outcomes across Urban, Suburban, and Rural Settings. Peters GA, Ordoobadi AJ, Panchal AR, Cash RE. Prehosp Emerg Care, 2023;27:162–169.
Out-of-hospital cardiac arrest (OOHCA) survival has long been a benchmark for EMS services. Survival rates and return of spontaneous circulation (ROSC) vary across major cities in the USA and worldwide. Studies examining the impact of certain medications, equipment and personnel on outcome from OOHCA fill the literature. However, there is little evidence examining cardiac arrest ROSC and survival in rural areas.
The authors of this retrospective review seek to examine the outcome differences between urban and rural OOHCA. The authors used data gathered from the National EMS Information System (NEMSIS) for the one-year period ending December 31, 2018. Entry criteria was all cases in which cardiopulmonary resuscitation (CPR) was performed by EMS personnel. Exclusions from the study included; pediatric patients (age less than 18 years), traumatic injury, response time greater than 60 minutes, non-911 scene, and non-transport or termination of resuscitation.
During the study period there were 84,867 documented cases of cardiac arrests attended to by prehospital EMS providers in the US. After exclusions, there were 64,489 patients enrolled in the study. Of the total, 5,601 (8.9%) took place in the rural setting. Age and gender were similar between the rural and urban groups. ROSC was achieved in 34.1% of patients in the urban setting compared to 29.2% in rural locations. Overall, ROSC was obtained in 33.6% of all patients. Response times were longer in the rural setting (7.5 vs 5.9 minutes). In rural areas, BLS unit patient management occurred more often than in urban locations (7.4% vs. 4.2% respectively). In rural settings advanced airway management was less likely to be employed (41.9% vs. 49.1%). Failure rates for advanced airway management were slightly higher in the rural situations (6.6% vs 6.1% respectively). There were no statistically significant differences between the two groups for bystander CPR or the initial presentation of a shockable rhythm.
The authors conclude that OOHCA patients in the rural environment have less likelihood of ROSC than those in the urban settings. Although patents were similar in their presentations, response time was longer, primary BLS response was greater, and advanced airway placement was lower in the rural situations.
A major limitation to the study included the fact that while ROSC was measured, ultimate survival to discharge was not. The data gathered in the NEMIS database is voluntarily submitted by EMS agencies which could result in bias. There was a significant amount of missing but desired data in the NEMSIS database. Lastly, the results are not generalizable due to the fact that fewer than half of all EMS agencies in the US submit data to NEMSIS.
Research in EMS take place primarily in urban areas. This study looks at important factors comparing rural to urban EMS and the outcomes of OOHCA in each setting. Not all treatments and procedures provided by EMS may translate to improved success and outcomes in rural areas. The inherent limitations associated with rural settings such as longer response times and differences in level of care will impact patient outcomes. Further investigations need to take place in rural areas to assist in identifying specific treatments and procedures that will positively impact the populations served in rural America and rural areas worldwide.
