NAEMSP ABSTRACTS ABSTRACTS FOR THE 2015 NAEMSP SCIENTIFIC ASSEMBLY. Oral Abstracts

Transcription

1 NAEMSP ABSTRACTS ABSTRACTS FOR THE 2015 NAEMSP SCIENTIFIC ASSEMBLY Oral Abstracts 1. ADVANCED AIRWAY TYPE AND ITS ASSOCIATION WITH CHEST COMPRESSION FRACTION DURING CARDIAC ARREST Angela Jarman, Jonathan Brown, Christopher Burk, Scott Youngquist, University of Utah Background: The optimal strategy for airway management during cardiac arrest is uncertain. We hypothesized that placement of an endotracheal tube (ET) via direct laryngoscopy (DL) during cardiac arrest would be associated with decreased chest compression fraction compared to blind King LT (KLT) placement or placement of an ET tube via video laryngoscopy (VL). Methods: This was a review of prospectively collected data on chest compression quality in cardiac arrests. Data on airway interventions was abstracted by two blinded abstractors. The setting is an urban, fire-based EMS service with 40,000 calls annually, serving a daytime population of 500,000 with a tiered ALS/BLS response. Participants were: all adult cardiac arrest victims in whom resuscitation was attempted for at least 10 minutes. We excluded cases in which no advanced airway was attempted (n = 21 [15 of which due to early return of spontaneous circulation or early termination of efforts]), nasotracheal intubation was performed (n = 1) or airway management was not documented (n = 1). Interventions/Observations: Chest compression fraction was calculated by Zoll RescueNet Code Review software (Enterprise Edition v , Zoll Corp, Chelmsford, MA). Results: During the time period analyzed (11/01/2011 through 6/15/2014), data on 215 cardiac arrests was available for analysis. After exclusions 192 cases were available for analysis. The first airway attempted during arrest was KLT in 45 cases, DL in 110, and VL in 37. First pass success was 32/45 (71%) for KLT, 74/110 (67%) for DL, and 29/37 (78%) for VL (Fisher s exact p = 0.45). There were no differences in chest compression fraction between groups: KLT 0.93 (IQR ), DL 0.91 (IQR ), VL 0.92 (IQR ), Kruskal-Walls p = Conclusions: We found no evidence of an association between type of advanced airway first attempted and chest compression fraction in our analysis. Chest compression fractions were nearly identical between groups and suggest that strategies for minimizing interruptions to CPR are not substantially hindered by the choice of advanced airway. This analysis is limited by its modest sample size and non-randomized design and is thus susceptible to selection bias, confounding, and the effects of missing data. PREHOSPITAL EMERGENCY CARE 2015;19: doi: / SUPRAGLOTTIC AIRWAY USE IS ASSOCIATED WITH HIGHERCHESTCOMPRESSIONFRACTION THAN ENDOTRACHEAL INTUBATION DURING OUT-OF-HOSPITAL CARDIOPULMONARY ARREST Michael C. Kurz, David Prince, James Christenson, Jestin Carlson, Susanne May, Sheldon Cheskes, Steve Lln, Michael Aziz, Michael Austin, Christian Vaillancourt, Justin Colvin, Henry Wang, University of Alabama at Birmingham Background: Chest compression interruptions - such as those from endotracheal intubation (ETI) - are associated with poorer out-of hospital cardiac arrest (OHCA) survival. Select Emergency Medical Services (EMS) practitioners substitute ETI with supraglottic airway (SGA) insertion to minimize these interruptions, but the resulting effects upon chest compression fraction (CCF) are unknown. We sought to determine the differences in CCF between adult OHCA receiving ETI and those receiving SGA. Methods: We studied adult, non-traumatic OHCA patients enrolled in the Resuscitation Outcomes Consortium (ROC) PRIMED trial. Chest compressions were measured using compression or thoracic impedance sensors. We limited the analysis to those receiving ETI or SGA and >2 minutes of chest compression data before and after airway insertion. We compared CCF between ETI and SGA before and after airway insertion, adjusting for age, sex, witnessed arrest, bystander CPR, shockable initial rhythm, public location, PRIMED trial arm, and regional ROC center. We also compared the change in CCF for each airway technique and stratified these analyses by initial rhythm. We analyzed the data using t-tests and multivariable linear regression. Results: Of 14,955 patients enrolled in the ROC PRIMED trial, we analyzed 2,767 cases, including 2051 ETI, 671 SGA, and 45 both. Unadjusted pre- and post- airway CCF was higher for SGA than ETI (pre vs 0.706, difference % CI , ; post vs 0.724, difference % CI , ). Adjusted postairway CCF improved with both techniques, but the changes were not statistically significant (0.012 difference, 95% CI 0.036,-0.012, p-value 0.32). CCF differences were similar when stratified by initial rhythm. Conclusion: In this series SGA insertion was associated with a higher CCF than ETI and that difference persisted post-airway insertion. Advanced airway management strategy may minimally impact CCF. 3. THE IMPACT OF CHEST COMPRESSION FRACTION ON CLINICAL OUTCOMES FROM SHOCKABLE OUT-OF-HOSPITAL CARDIAC ARREST DURING THE RESUSCITATION OUTCOMES CONSORTIUM (ROC) PRIMED TRIAL Sheldon Cheskes, Robert Schmicker, Tom Rea, Judy Powell, Ian Drennan, Peter Kudenchuk, Christian Vaillancourt, William Conway, Ian Stiell, Dion Stub, Daniel Davis, Noah Alexander, Jim Christenson, Sunnybrook Centre for Prehospital Medicine/University of Toronto Background: The role of chest compression fraction (CCF) in resuscitation of shockable outof-hospital cardiac arrest (OHCA) is uncertain. We evaluated the relationship between CCF and clinical outcomes in a secondary analysis of the Resuscitation Outcomes Consortium (ROC) PRIMED trial. Methods: We included OHCA patients from the ROC PRIMED trial who suffered cardiac arrest prior to EMS arrival, presented with a shockable rhythm, and had cardiopulmonary resuscitation (CPR) process data for at least one shock. We used multivariable logistic regression adjusting for Utstein variables, CPR metrics of compression rate, perishock pause and ROC site to determine the relationship between CCF and survival to hospital discharge, return of spontaneous circulation (ROSC), and neurologically intact survival defined with Modified Rankin Score (MRS) 3. Due to potential confounding between CCF and cases that achieved early ROSC, we also performed an analysis restricted to patients without ROSC in the first 10 minutes of EMS resuscitation. Results: Among the 2,558 eligible patients, median (IQR) age was 65 (54, 76) years, 76.9% were male, and mean (SD) CCF was 0.70 (0.15). Compared to the reference group (CCF < 0.60), the odds ratio (OR) for survival was 0.57 (95%CI: 0.42, 0.78) for CCF and 0.32 (95%CI: 0.22, 0.48) for CCF Results were similar for outcomes of ROSC and neurologically intact survival. Conversely, when restricted to the cohort who did not achieve ROSC during the first 10 minutes (n = 1,660), the relationship between CCF and survival was no longer significant. Compared to the reference group (CCF < 0.60), the OR for survival was 0.85 (95%CI: 0.58, 1.26) for CCF and OR 0.87 (95%CI: 0.58, 1.36) for CCF Conclusions: In this observational cohort study of OHCA patients presenting in a shockable rhythm, CCF when adjusted for Utstein predictors, CPR metrics and ROC site was paradoxically associated with lower odds of survival. The relationship between CCF and clinical outcomes was null in a sensitivity analysis restricted to patients without ROSC in the first 10 minutes. CCF is a complex measure and taken by itself may not be a consistent predictor of clinical outcomes. 4. STATEWIDE IMPLEMENTATION OF A STANDARDIZED PRE-ARRIVAL TELEPHONE CPR PROGRAM IS ASSOCIATED WITH INCREASED BYSTANDER CPR AND SURVIVAL FROM OUT-OF-HOSPITAL CARDIAC ARREST Bentley Bobrow, Daniel Spaite, Micah Panczyk, Uwe Stolz, Tyler Vadeboncoeur, John Sutter, Blake Langlais, Arizona Department of Health Services 140

2 NAEMSP 2015 ANNUAL MEETING ABSTRACTS 141 Background: Bystander CPR (BCPR) increases survival from OHCA yet is provided in a minority of cases. The AHA has promulgated guidelines on the provision of pre-arrival Telephone CPR (TCPR) instructions and measurement to increase the proportion of BCPR; however, the impact of those guidelines on survival is unknown. The objective of this study was to describe the impact of a comprehensive bundle of TCPR protocol, training, data collection, and feedback on BCPR and survival from OHCA across the state of Arizona. Methods: audio recordings of confirmed OHCAs and suspected OHCAs (10/2010-6/2013) in 7 large centers were reviewed using a standardized time-stamp methodology linked with EMS and hospital process and outcome data. There were 2343 pre-implementation cases (P1) and 2291 cases post-implementation of a bundle of care (P2) that included staff training and guideline-based protocol changes, data collection and feedback to providers. Univariate and multivariable analyses were used to assess outcomes between P1 and P2. Results: There were 2532 OHCAs [1232 P1, 1300 P2; 64% male, median age 62 (IQR: 47-74)]. 83% of cases were identified in P1 compared with 89% in P2 (p<0.001). The rate of telephone-assisted BCPR went from 44% in P1 to 62% in P2 (p<0.001). Time to beginning TCPR instructions decreased from a median of 144 sec (P1) to 126 in P2 (p<0.001). Time to first chest compression also decreased (P1: 178; P2: 155; p<0.001). Outcome data are currently available for 64% of confirmed OHCAs (1630 patient outcomes with 1619 neuro outcomes). Survival was significantly higher in P2 (11.2%) compared to P1 (7.9%; p = 0.023), as was good neuro outcome (CPC-1 or 2: 7.7% P2 vs. 4.8% P1; p = 0.018). After adjusting for witnessed arrest, shockable rhythms, age, and sex, both survival and good neuro outcome were still significantly higher in P2 vs. P1 [adjusted odds ratios: survival = 1.5 (95% ); good neuro outcome = 1.7 (95% )]. Conclusion: The implementation of a comprehensive statewide TCPR bundle was associated with significant improvements in the rates of telephone-assisted BCPR, survival and good neurologic outcome after OHCA. 5. CARDIOPULMONARY BYPASS RESUSCITATION ON THE OUTCOMES AFTER OUT-OF-HOSPITAL CARDIAC ARREST:ANATIONWIDE OBSERVATIONAL AND PROPENSITY SCORE MATCHED ANALYSIS Sae Won Choi, Sang Do Shin, Eui Jung Lee, Kyoung Jun Song, Tae Yun Kim, Yu Jin Lee, Young Sun Ro, SeoulNationalUniversityHospital Background: Cardiopulmonary bypass (CPB) resuscitation has been used to support out-ofhospital cardiac arrest (OHCA) patients. This study aimed to determine whether CPB resuscitation is associated with improved OHCA outcomes compared to conventional cardiopulmonary resuscitation in Korea. Methods: We used a Korean national OHCA cohort database composed of hospital and ambulance data. We included all EMS-treated OHCA with presumed cardiac etiology for the period Jan to Dec excluding cases without available hospital outcome data. The primary exposure was CPB resuscitation during CPR in the emergency department (ED). The endpoints were survival to admission, hospital discharge with brain recovery (cerebral performance category 1 or 2). We compared outcomes between CPB versus non-cbp group using multivariable logistic regression for calculating adjusted odds ratios (ORs) and 95% confidence intervals (CIs), adjusting for individual, Utstein, post-resuscitation factors, and comorbidities, using original and propensity-score matched datasets. Results: Of 171,356 patients with OHCA, we included 70,704 excluding nontreated (n = 18,177), non-cardiac (n = 29,884), and unknown brain recovery at discharge (n = 55). Overall survival to admission and to discharge with good brain recovery was 14.0% and 2.4%, respectively. CPB was performed in 373 patients (0.5%). Yearly rates are as follows: 0.1% (2009), 0.2% (2010), 0.4% (2011), 0.7% (2012), and 1.0% (2013). Survival to admission was significantly higher in CPB group (80.4%) than non-cpb (13.7%) in original dataset (Adjusted OR = 8.14, 95% CI ). Discharge with good brain recovery was higher in CPB (9.9%) than non-cpb (2.4%) but adjusted OR (95% CI) was against CPB in the original dataset; 0.62 ( ). From propensity score matched dataset (N = 746 from 373 CPB cases and 373 non-cpb cases), survival to admission was significantly higher in CPB group (80.4%) than non-cpb (59.8%) (Adjusted OR = 6.31, 95% CI ). Discharge with good brain recovery was significantly lower in CPB (9.9%) than non-cpb (17.7%) with adjusted OR (95% CI); 0.50 ( ).Conclusions: CPB resuscitation has been increasing every year and is associated with higher survival to admission. However, it is not associated with an improved hospital discharge with good brain recovery in a nationwide observational study in Korea. 6. QUALITATIVE ANALYSIS OF THE CALLER-DISPATCHER INTERACTION DURING CALLS FOR VICTIMS EXPERIENCING OUT-OF-HOSPITAL CARDIAC ARREST Christopher T. Richards, Kenzie Cameron, Eddie Markul, Danielle McCarthy, Doreen Rottman, Frank Albarran, Patricia Lindeman, Leslee Stein-Spencer, Northwestern Feinberg SOM Background: Emergency medical dispatchers (EMDs) are critical to cardiac arrest survival through detecting out-of-hospital cardiac arrest (OHCA) and facilitating cardiopulmonary resuscitation (CPR). Little is known about how the communication characteristics of the caller- EMD interaction influence detection and treatment of OHCA. The objective of this study was to use qualitative methodology to describe the caller-emd interaction during calls for OHCA. Methods: We performed a qualitative study of calls for OHCA placed to a large urban dispatch center between July and November Cases were identified through a quality improvement initiative whereby the electronic medical record of the municipal EMS service was queried using the search term CPR ; 15% of these were randomly sampled for review. Exclusions included pediatric patients, calls from health care facilities, traumatic arrests, third party calls, arrests after EMS arrival, victims with do-not-resuscitate orders, and unintelligible calls. Field notes were drafted during audio review, and a multidisciplinary team rated the emotional content and cooperation score (ECCS) of callers (1 = normal conversational speech to 5 = uncontrollable, hysterical ). The study team then used a latent content and constant comparison approach for thematic analysis. Results: Fortysix calls were analyzed before saturation was achieved. Callers were generally anxious but cooperative, with a median and mode ECCS of 2 (IQR 1,3). Three themes regarding identification of OHCA were abstracted: 1) callers use disparate terms when describing cardiac arrest, 2) recognition of OHCA may be hindered if conditions mimicking OHCA (e.g. seizure) or the patient s past medical history are described (e.g. diabetes), and 3) how the dispatcher asks about OHCA influences detection of OHCA. An additional three themes regarding CPR initiation were abstracted: 1) directing rather than asking callers to perform CPR may increase CPR compliance, 2) specific CPR instructions assist callers to perform CPR, and 3) the emotional state of the caller or bystanders can limit CPR compliance. Conclusions: This qualitative analysis identified that characteristics of the caller-emd interaction influences both detection of OHCA and provision of CPR. Understanding the complex caller-emd interaction and developing dispatch protocols that acknowledge communication styles of callers may lead to initiatives that improve overall cardiac arrest survival. 7. SUFFICIENT CATHETER LENGTH FOR PNEUMOTHORAX NEEDLE DECOMPRESSION:A META-ANALYSIS Brian M. Clemency, Christopher Tanski, Michael Rosenberg, Joseph Consiglio, Heather Lindstrom, University at Buffalo Background: Needle thoracostomy is the prehospital treatment for tension pneumothorax. Sufficient catheter length is necessary for procedural success. We determined the minimum catheter length needed to enter the pleural space at the second intercostal space midclavicular line on a percentile basis. Methods: A meta-analysis of existing studies. Medline and PubMed searches were performed using the search terms: needle decompression, needle thoracentesis, chest decompression, pneumothorax decompression, needle thoracostomy, and tension pneumothorax. Studies were included if they published a sample size, mean chest wall depth, and a standard deviation or confidence interval. Two reviewers reviewed abstracts from all studies identified by the literature search to select studies that appeared to meet inclusion criteria. Two reviewers then reviewed selected full manuscripts to determine final inclusion. Sample size, mean chest wall depth, and standard deviation were found or calculated for each study. Data was combined assuming normal distribution to create a pooled dataset. Procedural success was defined as catheter length being equal to or greater than chest wall depth. Results: The literature search yielded 773 unique studies. All study abstracts were reviewed for possible inclusion. 18 studies were identified for full manuscript review. 13 studies met all inclusion criteria and were included in the meta-analyses. Pooled sample statistics were: n = 2558, mean 4.19 cm, and SD Minimum catheter length needed for success at the 70th, 80th, 90th and 95th percentile for chest wall size was found to be 4.91, 5.34, 5.61 and 6.44 cm respectively. Conclusion: A minimum catheter length of 6.44 cm in would be required for procedural success in 95% of the patients in this pooled sample. 8. PREHOSPITAL AND EMERGENCY DEPARTMENT OUTCOMES OF PATIENTS RECEIVING INTRANASAL NALOXONE BY FIRE DEPARTMENT FIRST RESPONDERS Jeffrey C. Moon, Jeremy Cushman, University of Rochester Background: The purpose of this study was to determine the efficacy, hazards, need for repeat dosages, and emergency department (ED) outcomes of patients receiving intranasal naloxone (INN) by Basic Life Support Fire Department first responders. Methods: Quality assurance data was utilized in conjunction with a structured chart review of prehospital and ED medical records to identify patients that had received prehospital INN by a single fire department first response agency between January 1, 2012 and January 15, 2014 and transported to a study hospital. A single abstractor reviewed all charts to determine pre- and

3 142 PREHOSPITAL EMERGENCY CARE JANUARY/MARCH 2015 VOLUME 19 / NUMBER 1 post-administration vital signs and Glascow Coma Scale (GCS), need for additional naloxone, patient and provider hazards, ED lengthof-stay (ED LOS), frequency of hospital admission, provision of addiction counseling, and recidivism. Results: 76 patients received INN during the study period. All had a GCS 3 prior to INN administration, average heart rate was 103 BPM (Range ) and average respiratory rate was 4.4 (0-14). 63/76 (83%) of patients were successfully reversed with a single administration of INN, with no complications, no intubation, and no requirements for additional naloxone. 13/76 (17%) patients required additional naloxone administration (11 received 2 doses, 2 received 3 doses). 7/76 (9%) of EMS providers documented patient agitation, while one patient required chemical sedation after opioid reversal because of uncontrolled agitation. No patients required intubation in the field and all patients were transported to an ED. No patients left the Emergency Department against medical advice. The average ED LOS for discharged patients was 8.4 hours (range 2-27 hours). 2/76 (3%) were admitted to the hospital. 73% received addiction counseling from ED resources. 72% had additional ED visits related to opioid abuse while 73% for other substance abuse (within 2 years of INN administration). No patients died. Conclusion: Asingle dose of INN provided successful reversal of 83% of patients. There were very few adverse events. Patients receiving INN in this system often have ED visits for concomitant opiate or other substance abuse, and not all patients receive addiction counseling. Inpatient admission is rare in this population, however ED length of stay is longer than national average. 9. REAL-TIME FATIGUE REDUCTION IN EMERGENCY CARE CLINICIANS:THE SLEEPTRACKTXT TRIAL Daniel Patterson, Daniel Buysse, Matthew Weaver, Jack Doman, Charity Moore, Brian Suffoletto, Kyle McManigle, Clifton Callaway, Donald Yearly, University of Pittsburgh Background: To assess early stage testing (performance characteristics) and impact of a novel text message (SMS) based intervention for reducing intra-shift fatigue among Emergency Medical Services (EMS) shift workers. Methods: We used a two-arm parallel, randomized, controlled and single blinded trial of 100 EMS workers using a 1:1 allocation (clinicaltrials.gov NCT ). Recruitment was open to any EMS clinician via a website. Participants received text messages/sms queries that measured their perceived sleepiness, fatigue, and difficulty with concentration at the beginning, every 4-hours during, and at the end of scheduled shifts. The intervention group received extra alertness-promoting text messages in real time if they reported a high level of sleepiness or fatigue. Control participants received the assessment-only text messages. Our principal measure of performance was compliance with text message queries. Data were analyzed under the intention-to-treat standard. We used mixed-effects models to control for multiple observations per participant. Results: Of the initial cohort, we assigned 48 to the intervention group and 52 as controls; 99 participants documented 2,621 total shifts over 90-days. The median number of scheduled shifts per participant was 24 shifts (IQR 19-34). No demographic differences identified between intervention and control groups after randomization (p>0.05). Half of scheduled shifts (48.4%) were >12-hours. Participants responded to 36,073 of 40,947 text-messages, for an overall compliance rate of 88.1%. Compliance did not differ between groups at the beginning of shifts (p = 0.06), during shifts (p = 0.93), or at end of shifts (p = 0.27). Intervention participants reported lower mean fatigue and sleepiness at 4 hours, 8 hours, and at the end of shift (12-hours) than control participants (p<0.05). Intervention participants saw improvement in sleep quality from baseline to 90-day follow up (p = 0.01). Conclusions: We observed positive performance of text messaging for fatigue assessment and intervention of EMS clinicians. Our pilot intervention was efficacious in reducing reported fatigue and sleepiness during long shifts. Text messaging is scalable and could be incorporated into fatigue risk management programs. 10. MORBIDITY AND MORTALITY ASSOCIATED WITH PREHOSPITAL LIFT ASSIST CALLS Michelle Klingel, Lauren Shephard, Shelley McLeod, Michael Lewell, Michael Peddle, Adam Dukelow, Matthew Davis, The University of Western Ontario Background: When an individual requires assistance with mobilization, emergency medical services (EMS) may be called. If a patient does not receive treatment on scene and is not transported to hospital for medical attention, these are referred to as Lift Assist (LA) calls. The factors contributing to individuals inability to mobilize on their own are often overlooked or not appreciated. It is possible this need for assistance represents a subtle-onset of a disease process or decline in function. Without recognition or treatment, the patient may be at risk for recurrent falls, repeat EMS visits or worsening illness. The objective was to determine the 14 day morbidity and mortality associated with LA calls. Methods: All LA calls from a single EMS agency were collected over a one-year study period (Jan - Dec 2013). LAs were identified based on a final problem code of lift assist required or no complaints from the ambulance call record. These calls were linked with hospital records to determine if LA patients had a subsequent visit to the emergency department (ED), admission, or death within 14 days. Results: There were 42,055 EMS calls in the study period; 808 (1.9%) were LA calls. These calls were for 428 individuals; 313 (73.1%) patients had 1 LA, and 115 (26.9%) patients had >1 LA call. The number of LA calls per patient ranged from 1 to 34. Mean (SD) age was 74.8 (14.1) years and 45% were male. Age and gender did not differ between those who had only 1 LA in the time period, versus those with >1 LA. There were 169 (20.9%) ED visits, 93 (11.5%) hospital admissions and 9 (1.1%) deaths within 14 days of a LA call. Of those patients admitted to hospital, 71 (76.3%) were admitted under general medicine and median (IQR) hospital length of stay was 7 (4, 15.5) days. Conclusions: LA calls are associated with short-term morbidity, mortality and considerable use of EMS and hospital resources. These calls may be early indicators of problems requiring comprehensive medical evaluation. Further research is required to identify predictors associated with higher risk of morbidity and mortality in LA patients. 11. EXPLORING THE VALUE OF HOSPITAL-BASED PARAMEDIC EDUCATION Justin Mausz, Walter Tavares, Centennial College Background: Clinical (i.e., hospital-based) placements are compulsory in paramedic entry-to-practice education. However, student volume leading to overcrowding or declining access, and concerns over patient privacy and safety make securing clinical placements for trainees challenging. Furthermore, the learning context (i.e., an acute care hospital) differs substantially from the eventual practice context, raising questions regarding educational relevance while also making alternative learning strategies (e.g., simulation) attractive. Therefore, the aim of this study was to explore the value and role of clinical placements in paramedic education. Methods: Fifty-three subjects representing four key stakeholder groups (11current students, 13 recent graduates, 16 paramedic program faculty and 13 program coordinators/directors) took part in a series of semi-structured focus groups. All groups were asked to reflect on the value and role of clinical placements in paramedic trainee development as well as the suitability of simulation as a potential supplement or replacement. All sessions were audio recorded and transcribed verbatim. Two researchers independently analyzed the transcripts using inductive thematic analysis. Results: Participants expressed educational features that were in support of continued involvement in clinical (i.e., hospital) based education, including engagement through realism (i.e., the benefits of examining and treating unwell patients, often citing the limitations of simulation), scaffolding (i.e., preparation for paramedic contexts), an improved awareness of the broader healthcare system, and the development of technical and interpersonal competencies. Clinical placements may serve to normalize some of the more difficult aspects of working in healthcare (e.g., suffering, disease), promoting psychological resiliency in trainees. Finally, variability in student experiences (e.g., patient types, practice opportunities, feedback etc.) and poor alignment with some educational goals emerged as threats to clinical-based education. Conclusion: The emerging narrative was that clinical placements provide students a nuanced learning experience, beyond what classrooms or simulations can provide, that prepares them academically, clinically and psychologically for paramedic contexts. This study suggests clinical placements for paramedics should be maintained, but that improved educator control over the learning and/or flexible curriculum models may be required. 12. EMS PROVIDER ATTITUDES AND PERCEPTIONS TOWARDS PREHOSPITAL EFIC RESEARCH Jamie Jasti, Antonio Fernandez, Terri Schmidt, Brooke Lerner, Medical College of Wisconsin Background: Previous research has shown that most EMS providers with previous clinical trial experience are supportive of enrolling patients in Exception from Informed Consent (EFIC) studies. However, the opinion of the broader EMS provider population is unknown. The purpose of this study was to evaluate the attitudes and opinions of a broad population of EMS providers on enrolling patients in EFIC studies. Methods: A survey was conducted in 2010 of all EMS providers who participated in the National Registry of Emergency Medical Technicians (NREMT) registration process, which included half of all registered providers. Each registration packet included our optional survey, which had 9 sixpoint Likert scale questions concerning their opinion of EFIC studies as well as 8 demographic questions. Responses were collapsed to agree and disagree and then analyzed using descriptive statistics with 99% confidence intervals. Results: A total of 65,993 EMS providers received the survey and 23,832(36%) participated. Most respondents agreed (98.4%, 99%CI: ) that EMS research is important, while only 46.6% (99%Cl: ) were personally willing to be enrolled in an EFIC study. 77.0% (99%Cl: ) of respondents agreed that the rights of research subjects are more important than the interests of the general

4 NAEMSP 2015 ANNUAL MEETING ABSTRACTS 143 community. 30.9% (99%CI: ) agreed with enrolling patients without their consent when it is important to learn about a new treatment. A majority of respondents felt that there are enough safeguards for EFIC studies (70.6%, 99%Cl: ) and that investigators have good intentions (91.7%, 99%Cl: ). When determining who should be able to decide to participate in an EFIC study, 68.5% (99%Cl: ) of respondents said the individual EMS provider, 81% (99%Cl: ) the EMS medical director, and 73.4% (99%Cl: ) the EMS administrator. Conclusion: While the majority of EMS providers agree that EMS research is important, considerably less agree with enrolling patients without consent in EMS research and less than half would be willing to be enrolled in EFIC studies themselves. These findings are similar to the previous survey of EFIC-experienced providers. Researchers should discuss with EMS providers their perceptions of EFIC studies before beginning a study and plan for their concerns. 13. PREHOSPITAL RED BLOOD CELL TRANSFUSION IS ASSOCIATED WITH IMPROVED EARLY OUTCOMES IN AIR MEDICAL TRAUMA PATIENTS Joshua B. Brown, Francis Guyette, Jason Sperry, Anisleidy Fombona, Timothy Billiar, Andrew Peitzman, University of Pittsburgh Background: Hemorrhage is the leading cause of survivable death in trauma. Hospital-based resuscitation strategies including early red blood cell (RBC) transfusion have reduced this. Prehospital (PH) use of RBC transfusion is growing, and preliminary evidence suggests improved outcomes. The objective of this study was to evaluate the association of PH RBC transfusion with early outcomes in trauma patients undergoing air medical transport. Methods: This was a retrospective cohort study of trauma patients transported by a large air medical provider to an urban level- I trauma center from Patients undergoing PH RBC transfusion were propensityscore matched to control patients (no PH RBC) in a 1:2 ratio based on transfer status, PH physiology, crystalloid and transfusion volume, and transport distance. Outcomes included 24-hour survival, shock on admission (BD 6mEq/L or lactate>4mmol/l), and 24- hour RBC requirement. Acute respiratory distress syndrome (ARDS) was evaluated as a safety outcome. Conditional logistic regression and mixed-effects linear regression were used to determine the association of PH RBC transfusion with the outcomes of interested controlling for confounders not used in the matching procedure. Subgroup analysis was performed for patients transported from the scene of injury. Results: 240 patients treated with transfusion were matched to 480 controls. PH RBC was associated with increased probability of 24- hour survival (AOR 6.83; 95%CI 1.67, 27.95, p = 0.01), lower risk of shock (AOR 0.28; 95%CI 0.09, 0.85, p = 0.03), and lower 24-hour RBC requirement (Coef -2.8; 95%CI -5.6, -0.08, p = 0.04). ARDS was similar between groups (2% vs. 3%, p = 0.61). Among matched patients transported from the scene (PH RBC n = 71, control n = 142), PH RBC was also associated with increased probability of 24-hour survival (AOR 6.31; 95%CI 1.88, 21.14, p<0.01), lower risk of shock (AOR 0.24; 95%CI 0.07, 0.80, p = 0.02), and lower 24-hour RBC requirement (Coef -3.4; 95%CI -6.5, -0.24, p = 0.03). ARDS was again similar between groups (4% vs. 1%, p = 0.07) Conclusions: After propensityscore matching, PH RBC was associated with an increased probability of 24-hour survival, decreased risk of shock, and lower 24-hour RBC requirement. PH RBC appears beneficial in severely injured air medical trauma patients and prospective study is warranted. 14. ASSOCIATION BETWEEN LOWEST PREHOSPITAL SYSTOLIC BLOOD PRESSURE AND NON-MORTALITY OUTCOMES IN MAJOR TRAUMATIC BRAIN INJURY:IS THERE A HYPOTENSION THRESHOLD? Uwe Stolz, Kurt Denninghoff, Dan Spaite, Bently Bobrow, Vatsal Chikani, Duane Sherril, BruceBarnhart, Josh Gaither, David Adelson, Chad Viscusi, Terry Mullins, Will Humble, University of Arizona Background: The current Prehospital Traumatic Brain Injury-TBI Guidelines utilize an SBP threshold of <90mmHg for treating hypotension in patients 10 years. This was based primarily upon the general population s distribution of SBP rather than clinical/physiological data. Our previous work failed to identify a treatment threshold for SBP related to the risk of mortality. To our knowledge, this question has never been evaluated for non-mortality outcomes. Our hypothesis: In a statewide, multisystem evaluation of major TBI, 90mmHg is not a clinically-supportable SBP cut-point for hypotension for three non-mortality outcomes [Admission to ICU, ICU days, inpatient disposition home (vs. rehab, long term care, etc.)]. Methods: All moderate/severe TBI cases (CDC Barell Matrix Type-1) in the Excellence in Prehospital Injury Care (EPIC) TBI Study (NIH/NINDS-1R01NS071049) from 1/1/08-12/31/12 with a lowest recorded prehospital SBP between 40 and 120 mmhg were included (exclusions: age<10, death prior to hospital discharge). Fractional polynomials (FP) with logistic regression (ICU Admission, inpatient disposition home [vs. rehab/skilled nursing facility]) and negative binomial regression (ICU days) were used to analyze outcomes using adjusted odds ratios (aor) and incidence rate ratios (airr), controlling for important risk factors/confounders. Results: 4,390 patients met inclusion criteria. SBP was linearly associated with all outcomes in the log scale. No FP transformation improved any model fit compared to un-transformed (linear) SBP. Each fivepoint increase of SBP decreased odds of ICU admission by 5.1% (aor = 0.949, 95% CI: ), increased odds of disposition home by 11.1% (aor = 1.111, CI: ), and decreased ICU days by 5.2% (airr = 0.948, CI: ) across the range of SBP from 40 to 120mmHg, after controlling for ISS, prehospital SpO2, AIS-head, age, sex, payer, race, ethnicity, trauma type, interfacility transfer, and clustering by trauma center. Conclusion: In major TBI, we found a linear relationship between lowest prehospital SBP and three important non-mortality outcomes across a wide range of SBP (40-120mmHg). The concept that 90mmHg represents a unique or important cut-point is not supported by these data. For the injured brain, clinically meaningful hypotension may be higher than current guidelines suggest and further work is needed to identify an optimal target for fluid resuscitation in TBI. 15. EMS PROVIDER PERSPECTIVES REGARDING PELVIC TRAUMA:AN EXPLORATORY FOCUS GROUP STUDY Yutaka Yamaguchi, Mohamud Daya, Zhen Zhu, Oregon Health & Science University Background: Our EMS system introduced external binding to stabilize suspected pelvic fractures in Experience to date suggests that providers rarely stabilize suspected pelvic injuries before arrival at the hospital. We conducted a focus group study to better understand EMS provider perspectives regarding pelvic trauma. Methods: This was a mixed methods study of EMS providers practicing in the Portland-Vancouver metropolitan region. Participants were recruited by an invitation letter sent to all provider levels (EMT- Basic, EMT-Intermediate, EMT-Paramedic) affiliated with public and private agencies. EMS providers follow similar treatment protocols which include consideration of external binding in the context of high energy mechanisms or physical findings suggestive of pelvic instability. An independent facilitator led the interviews using a semi-structured scripted questionnaire. Questions addressed issues such as pelvic fracture epidemiology, mechanism of injury, clinical features and treatment considerations. We collected participant demographic information including EMT level, agency affiliation (private vs. public), type of practice (rural vs. urban) and years of field experience. Responses were analyzed by grouping into themes to develop a conceptual framework. Results: We interviewed 18 participants in 4 distinct focus groups. Four were EMT-Basic s with 3-7 years of experience. Fourteen were paramedics with a mean experience of 14 years. Thirteen providers were from private agencies, 5 were from public agencies. Eight worked in rural areas, 7 in urban areas and 3 in both. Several themes emerged: 1) inconsistent knowledge regarding mechanism of injury, incidence, potential severity and treatment considerations for pelvic injuries 2) concerns over accuracy of field pelvis assessment 3) competing treatment priorities related to airway, breathing and circulation concerns identified during the primary survey 4) delayed assessment of the pelvis during the secondary survey by which time patients were already packaged for transport 5) lack of feedback on unrecognized pelvic injuries 6) limited initial and retraining opportunities on pelvic binding and stabilization techniques 7) resistance to the use of pelvic binding in the perceived absence of effectiveness data. Conclusion: Several factors contribute to the failure to identify and stabilize pelvic fractures in the field. Many of these could be addressed through education, training and quality improvement efforts. 16. ASTRETCHER MATTRESS,WITHOUT THE LONG SPINE BOARD,SIGNIFICANTLY REDUCES LATERAL MOVEMENT OF THE HEAD,TORSO, AND HIP DURING EMS TRANSPORT David Wampler, Craig Cooley, Chloe Pineda, Joan Polk, Emily Kidd, Dale Leboeuf, Marti Flores, Mike Shown, University of Texas Health Science Center at San Antonio Background: Although neurological deficits occur in less than 1% of trauma patients, historically EMS agencies have emphasized limiting spinal motion during transport of the trauma victim to the emergency department. The long spine board (LSB) has been the mainstay of spinal motion restriction practices, despite the paucity of data demonstrating effectiveness or improved outcomes. Use of the LSB, as with any medical device, comes with risks and benefits. The purpose of this study was to compare the lateral motion allowed by the LSB to that allowed by stretcher mattress alone. Methods: This was a randomized controlled 2-way crossover trial in which healthy volunteer subjects were randomly assigned to be secured initially to either LSB or stretcher mattress only. All subjects were fitted with a rigid cervical collar and foam headblocks for both immobilization mechanisms. Subjects were secured to the assigned device, and driven at low speed (<15 mph) on a closed course with a prescribed set of 15 right and 15 left turns. Upon completion, the subjects were then secured to the other device and the course repeated. Each subject

5 144 PREHOSPITAL EMERGENCY CARE JANUARY/MARCH 2015 VOLUME 19 / NUMBER 1 was fitted with 3 graduated-paper disks (head, chest, hip). Lasers were affixed to an engineered scaffold attached to the stretcher bridging over the patient allowing for patient movement to be measured relative to the stretcher. During transport, the degree of lateral movement was recorded during each turn. Significance was determined by t-test. Results: In both groups, the head demonstrated the least motion with 0.46 ± 0.4 cm mattress and 0.97 ± 0.7 cm LSB (p = <.0001). Lateral movement at the torso and hip was greater than the head with 1.22 ± 0.9 cm mattress vs 2.22±1.4 LSB (p = <.0001) for torso, and 1.20 ± 0.9cm mattress vs 1.88 ± 1.2cm LSB (p = <.0001) for hip. Additionally, when lateral movement is plotted as a function of body mass index, there is a significant direct correlation. Conclusions: The stretcher mattress alone allows 82% less lateral patient movement at the chest 57% less lateral movement at the hip than the LSB does in the immobilized patient, and the chest moves more than the head. Posters 17. THE EFFICACY OF LUCAS IN PREHOSPITAL CARDIAC ARREST SCENARIOS:ACROSSOVER MANNEQUIN STUDY Robert A. Gyory, Scott Buchle, Jeffrey Lubin, Penn State College of Medicine Background: High quality CPR is considered critical in resuscitation from cardiac arrest. When EMS personnel are attempting resuscitation, multiple factors may hinder high quality CPR performance. We hypothesized that, in a realistic prehospital cardiac arrest scenario, the LUCAS device would provide consistently higher quality CPR while not increasing time to defibrillation. Methods: We performed a crossover controlled study in which a recording mannequin was placed in a commercial building as a simulated cardiac arrest patient in ventricular fibrillation. A standard two person EMS crew responded, performed defibrillation, and provided CPR with either manual chest compressions or compressions by LUCAS. The team transported the mannequin through the building, down stairs, to an ambulance, and to a local Emergency Department. After a 30 minute rest period, they repeated the scenario with the opposite chest compression method. The order of the chest compression technique used was randomized. The scenario was timed with manually marked critical events and the mannequin provided data on compression characteristics. Data analysis utilized Wilcoxon signed rank testing. Results: Twenty-three paramedics and EMTs participated. LUCAS had a significantly different median compression rate (112/minute) vs. manual CPR (125/minute, p<0.01) and percent appropriate compression rate (71% vs. 40%, p<0.01). LUCAS performed no differently in median compression depth (36mm vs. 37mm, p = 0.83), but had a higher percent of compressions with adequate depth (52% vs. 36%, p<0.01). LUCAS performed no differently in median compression release depth (0mm vs. 0mm, p = 0.084), percent fully released compressions (93% vs. 78%, p = 0.67), or percent correct hand position (91% vs. 96%, p = 0.83). LUCAS had lower percent total scenario hands off time (15% vs. 20%, p<0.01). Median time to first defibrillation was not significantly different for LUCAS (132s) compared to manual CPR (123s, p = 0.97). Conclusions: In this study, using LU- CAS resulted in a compression rate more consistent with AHA guidelines and decreased total hands off time when compared against manual CPR. Defibrillation was not delayed. Median compression depth, release depth, and hand position were not significantly different, although the data suggests more consistent performance with LUCAS. There may be some advantages to using LUCAS in the EMS environment. 18. DOES SELF-DEBRIEFING WITH ADDITIONAL BIOMECHANICAL HINTS OF CHEST COMPRESSION POSES A BETTER IMPROVEMENT IN HANDS-ONLY CARDIOPULMONARY RESUSCITATION TRAINING? Yi-Ming Weng, Chi-Chun Lin, Chin-Shan Ho, Chan-Wei Kuo, Chang Gung Memorial Hospital, Linko, Taiwan Background: This study aimed to examine whether self-debriefing with additional biomechanical hints of chest compression poses a better improvement in hands-only cardiopulmonary resuscitation (CPR) training. Methods: This is a prospectively randomized control trial among emergency medical technicians (EMT) who were under EMT-II training in Taoyuan County fire department, Taiwan. The participants of control group received self-debriefing with current guidelines for CPR and the results of each own pretest result. In addition, four biomechanical hints of chest compression were given in experiment group: 1. Confirm kneeling position close to the patient side, 2. Leaning forward, arm and palm root vertical, 3. Elbows straight, 4. Head up and back flat (figure 1). Posttest was held at least 30 minutes after pretest. All parameters of quality of CPR were collected using a manikin (Resusci Anne with QCPR, Laerdal). Results: Of the 45 participants, 22 and 23 were allocated into control and experiment group, respectively. All participants were blinded to the purpose of the study. There was no significant difference of baseline characteristics between groups, including, sex, age, body weight, height, length of arm and leg, and exercise habits (Table 1). There were 5 projects of quality of CPR taken into account, including hands position, rate, depth, fully recoil, and hands-on time. The performance was worst in project of fully recoil (control vs experiment group, median; 38.0 vs 3.0%), followed by adequate depth (96.0 vs 55.0%), and rate (90.0 vs 43.0%; Table 2, Figure 2). Table 3.1 demonstrated significant improvement of average percentage of 5 projects in experiment group than control group with a median of 17.4 vs 2.3% (p = 0.041). In contrast, the difference of improvement was limited via subgroup analysis using those who did not fulfill an average of 80.0% of 5 projects in pretest (17.2 vs 18.3%, p = 0.555) Conclusions: Self-debriefing with additional biomechanical hints of chest compression pose a fair improvement in hands-only CPR. Further study using modify study design in different scale is of interest. 19. THE ASSOCIATION BETWEEN ETC02 AND CHESTCOMPRESSION DEPTH DURING PREHOSPITAL RESUSCITATION:ETCO2ALONE IS INADEQUATE TO ASSESS CPR QUALITY Bentley Bobrow, Daniel Spaite, Ryan A. Murphy, Annemarie Silver, Robyn McDannold, Margaret Mullins, Chris Kaufman, Uwe Stolz, Arizona Department of Health Services Background: International Guidelines recommend measurement of ETC02 to assure CPR quality and optimize blood flow in individual patients during CPR. Numerous factors impact ETC02 (ventilation, metabolism, flow, down time) and there are limited clinical studies correlating CPR quality and ETCO2 during actual prehospital resuscitations. Purpose: To assess the association between CC depth and ETCO2 during prehospital CPR. Methods: This is an observational study of prospectively collected CPR quality data from a statewide resuscitation QI program. CPR quality was measured using an accelerometer-based sensing technology (E Series, ZOLL Medical) during resuscitative efforts of OHCA patients treated by 2 EMS agencies. All non-ems witnessed adult ( 18 years) arrests of presumed cardiac etiology (10/ /2013) were included. ETC02 collectors were reviewed using Code Review software. CC depth and mean ETCO2 data were compiled for each minute when patients had no spontaneous circulation. Excluded timeframes: first minute after intubation, documented ROSC, or ETCO2 >50mmHg). Multivariable repeated measures regression was used to quantify the correlation between CC depth and log transformed ETCO2. Results: Among 1,522 OHCA patients, 1077 (71%) had CPR quality data, of which 429 (40%) were intubated. 170/429 (40%) of these had adequate ETCO2 data during CPR (study population; mean age 64.9 years; 64% male. CC depth was significantly related to ETCO2 (p = ) for survivors. On average, in the model, deeper compressions were associated with higher ETCO2 with each increase in 1 mm of CC depth corresponding to an increase in ETCO2 of 1.1 mmhg (controlling for CC rate and minutes into CPR). CC depth was not significantly related to ETCO2 (p = 0.147) for non-survivors. However, despite these statistical findings in the model, the scatter plot of individual patients reveals wide variation. Conclusion: Across this study population, ETC02 was correlated with CC depth. However, there is wide variation in individual patients. Many factors influence ETC02, making it far from optimal as a stand-alone individual patient measurement tool for CPR quality. The ideal model that maximizes blood flow in individual patients will require multiple simultaneous modalities of monitoring (e.g. measurement of CPR quality metrics, ventilation rate, and depth) as opposed to a universal numerical Guideline approach. 20. CHEST COMPRESSION RELEASE VELOCITY DECLINES OVER TIME DURING CPR Taro Irisawa, Bentley Bobrow, Daniel Spaite, Uwe Stolz, Annemarie Silver, Tyler Vadeboncoeur, Arizona Department of Health Services Background: Maintaining perfusion during CPR is essential to maximize outcomes after out-of-hospital cardiac arrest (OHCA). Chest compression release velocity (CCRV) was recently shown to be strongly associated with both improved survival and neurologic outcome, likely due to its influence on blood flow. There are no data describing what occurs to CCRV over time during CPR. Purpose: To analyze CCRV over time during prehospital cardiac resuscitation. Methods: This is an observational study of prospectively collected CPR quality data from a statewide resuscitation QI program. CPR quality was measured using a defibrillator with accelerometer-based sensing technology (E Series, ZOLL Medical) during resuscitative efforts of OHCA patients treated by 2 EMS agencies. All non-ems witnessed adult ( 18 years) arrests of presumed cardiac etiology (10/ /2013) were included. CCRV is defined as the maximum anterior/posterior velocity (mm/sec) achieved during the release phase of compressions. Means were calculated for each minute across the entire study group and slopes across minutes compared using linear regression with robust, cluster-adjusted standard errors. Results: Among 762 OHCA patients, 579 (76%) had full CPR quality data. Graphical presentation of data will be presented at the conference. There is a dramatic decrease in CCRV between the initiation of compressions and minute 4, dropping in a linear fashion from a mean of 354mm/sec to 334mm/sec (slope = -5mm/sec/min, 95% CI: