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References and Links to Papers

Airway Management.jpg


Maintaining an airway and ensuring effective ventilations is a corner stone to patient care. For those in pre-hospital emergency medical training the successful combination of knowledge and kinetic skills is essential. Traditional pre-hospital instruction has consisted of lecture and skills practice utilizing manikins. Recently selected pre- hospital education programs have begun utilizing human cadaver based workshops to reinforce skill sets for those in initial training.

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Emergency Medical Service (EMS) personnel in our region are often tasked with making the decision to call a “Heart Alert” setting in motion hospital preparations to receive the most time-sensitive form of heart attacks. It has been demonstrated that a significant hospital cost is associated with each heart alert activation.
The ECG test was given to 42 paramedics resulting in 1050 ECG pairs assessed. Each ECG pair had at least 1 inconsistency with a total of 183 inconsistencies. Of the inconsistencies, 94 (51%) followed the pattern of calling a heart alert with the computer interpretation of AMI; and not calling a heart alert on the same ECG if the computer interpretation was blinded. Twenty five true AMIs were not identified without the computer generated interpretation. Two ECGs revealed AMI where the computer algorithm failed to recognize it; paramedics were twice as likely to appropriately identify those AMIs when the computer interpretation was blinded.
Historically, the computer’s interpretation of the 12-Lead ECG has been identified as hypersensitive, resulting in false positive interpretations of Acute Myocardial Infarction (AMI). It is imperative that paramedics are able to accurately interpret a 12- Lead ECG in order to improve reliability, reduce delay to definitive care, and thus potentially improve morbidity and mortality.

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To compare the infusion rates between the Belmont FMS 2000 rapid infusion device (RID) and pressure bag assisted flow through an intraosseous needle in the proximal tibia and proximal humerus using a swine (Sus Scrofa) model. Our secondary objectives were to determine at what pressure maximal flow rates occur, and to determine if infusions at these pressures cause bony damage or local vascular extravasation.

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Intraosseous access in the proximal humerus has been demonstrated to deliver high infusion rates with rapid drug delivery to central circulation for the critically ill or injured. Studies demonstrate clinicians can access the proximal humerus with a high degree of success in the classroom or laboratory setting, but literature review offers no studies on paramedic humeral intraosseous success in the out of hospital cardiac arrest patient.
Study Objectives: Identify paramedic success in obtaining humeral intraosseous cannulation during cardio-cerebral resuscitation

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Historically, many bones have been successfully used for intraosseous vascular access (IO). These sites include the proximal tibia, sternum, distal tibia, radius, clavicle, proximal humerus, olecranon, calcaneous, iliac crest and distal femur.1 2 Since the distal femur location is a preferred site for IO among some pediatric emergency medicine physicians and allied health professionals, we sought to determine the clinical experience with the site for delivery of fluids and medications. Though the distal femur site has been approved for second generation IO devices by the European Union, as well as routinely discussed in standardized pediatric training, the site has not been cleared by the US FDA. As such the distal femur insertions site has been limited in it’s adoption.

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The ability to safely access numerous anatomical locations for intraosseous (IO) access would aid providers of emergency medicine when selecting suitable insertion sites in the emergent care setting. This pilot study was designed to compare flow dynamics and catheter stability of the distal femur and proximal tibia by evaluating the vascular pathways, intramedullary pressure, stability, and comparative human anatomy for the two sites.

IO Flow.jpg


Intraosseous (IO) vascular access involves inserting a needle into the bone-marrow cavity for administering fluids and medications. Traditionally, the proximal tibia site has been most commonly used, but there is new interest in the proximal humerus site due to fluids typically flowing easier through the humerus. The IO flow rates achievable using the proximal humerus and proximal tibia insertion sites were compared through two healthy human studies.

IO Pain.jpg


Intraosseous (IO) access is an effective tool for vascular access when patients have emergent, urgent or medically necessary conditions and traditional intravenous access is difficult.1−2 In the majority of cases, two actions are required for optimal IO infusions: a syringe flush after initial catheter insertion and use of a pressure device (pressure bag or infusion pump) for fluid administration. One study found mean pain levels reported by patients with a Glasgow Coma Score of >12 increased from 3,5 on insertion to 5.5 with pressurized infusion.3 For alert patients, managing the pain associated with the pressure required for optimal IO infusions is imperative.
Two healthy human volunteer studies were designed to evaluate the effectiveness of 2% preservative-free lidocaine to mitigate the pain at two dose ranges (phase 1), various infusion flow pressures and interventions and to compare the level of pain experienced during IO infusion between the tibial and proximal humeral sites.

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Competency maintenance is challenging in the health care environment. Ensuring medical professional procedural proficiency at both the cognitive and psychomotor level can be a daunting task for institutions and services as well as the individual health care professional. The perceived predictability of procedural competence is confounded by frequency of use, institutional support and the allocation of time for all parties involved. Compounding the issue is the unpredictable frequency of applicable patient encounters.
Literature currently addressing competency maintenance includes psychomotor proficiency practice and specifically associated medical knowledge. Several studies have revealed that an individual’s procedural competency rapidly decays over time. Supportive evidence of this decay can be found globally in areas such as cardio-cerebral resuscitation.
Traditionally, medical institutions and services procedural evaluate personnel on an annual or semi-annual basis; however, literature review offers minimal insight as to a quantitative assessment of the degradation for both cognitive and psychomotor knowledge in the trained professionals.
The purpose of this study was to investigate the degree of cognitive and psychomotor knowledge retention over a specified time period. An effort was also made to assess any procedural retention differences between experienced medical professionals versus those considered new to the profession. This study was constructed as a prospective, quality assurance centered, assessment of rural emergency medical service providers during a standard protocol update and in-service.

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Intraosseous (IO) needle placement is often used for vascular access as an emergent alternate to peripheral venous access and additionally for applications such as bone marrow sampling and vertebroplasty. For over 85 years clinicians have placed IO needles into bone using either the manual technique of twisting and pushing or hammering with varied results. Within the last decade rotary powered IO devices have been introduced offering the clinician a third method of IO access. Increased awareness of this technology has raised questions concerning device control and the ability of clinicians to discern needle tip location within the bone while relying on tactile feedback. Tactile feedback has been widely accepted as the predominant method of discerning correct IO placement in most clinical settings, especially those required in emergent medicine. This study was designed to determine the relative precision of needle placement using only tactile feedback. This study additionally assessed the ability of each insertion method to access simulated osteoporotic bone without damage.

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