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Biomedical subjects

Marc Eckstein

Publications and source records attributed to Marc Eckstein.

At least 19 recordsLinked to original sources
PubMed2006

Rationale for establishing regional ST-elevation myocardial infarction receiving center (SRC) networks.

Recent developments have provided a unique opportunity for the organization of regional ST-elevation myocardial infarction (STEMI) receiving center (SRC) networks. Because cumulative evidence has demonstrated that rapid primary percutaneous coronary intervention (PCI) is the most effective reperfusion strategy for acute STEMI, the development of integrated SRC networks could extend the benefits of primary PCI to a much larger segment of the US population. Factors that favor the development of regional SRC networks include results from recently published clinical trials, insight into contemporary STEMI treatment patterns from observational registries, experience with the nation's current trauma system, and technological advances. In addition, the 2004 American College of Cardiology/American Heart Association STEMI guidelines have specified that optimal "first medical contact-to-balloon" times should be <90 minutes, so a clear benchmark for timely reperfusion has been established. Achievement of this benchmark will require improvements in the current process of care as well as increased multidisciplinary cooperation between emergency medical services, emergency medicine physicians, and cardiologists. Two types of regional SRC networks have already begun to evolve in role-model cities, including prehospital cardiac triage and interhospital transfer. Regional coordination of SRC networks is needed to ensure quality monitoring and to delineate the ideal reperfusion strategy for a given community based on available resources and expertise.

Angioplasty, Balloon, Coronary↗
PubMed2006

Helicopter scene transport of trauma patients with nonlife-threatening injuries: a meta-analysis.

BACKGROUND: Helicopters have become a major part of the modern trauma care system and are frequently used to transport patients from the scene of their injury to a trauma center. While early studies reported decreased mortality for trauma patients transported by helicopters when compared with those transported by ground ambulances, more recent research has questioned the benefit of helicopter transport of trauma patients. The purpose of this study was to determine the percentage of patients transported by helicopter who have nonlife-threatening injuries. METHODS: A meta-analysis was performed on peer-review research on helicopter utilization. The inclusion criteria were all studies that evaluated trauma patients transported by helicopter from the scene of their injury to a trauma center with baseline parameters defined by Injury Severity Score (ISS), Trauma Score (TS), Revised Trauma Score (RTS), and the likelihood of survival as determined via Trauma Score-Injury Severity Score (TRISS) methodology. RESULTS: There were 22 studies comprising 37,350 patients that met the inclusion criteria. According to the ISS, 60.0% [99% confidence interval (CI): 54.5-64.8] of patients had minor injuries, According to the TS, 61.4% (99% CI: 60.8-62.0) of patients had minor injuries. According to TRISS methodology, 69.3% (99% CI: 58.5-80.2) of patients had a greater than 90% chance of survival and thus nonlife-threatening injuries. There were 25.8% (99% CI: -1.0-52.6) of patients discharged within 24 hours after arrival at the trauma center. CONCLUSIONS: The majority of trauma patients transported from the scene by helicopter have nonlife-threatening injuries. Efforts to more accurately identify those patients who would benefit most from helicopter transport from the accident scene to the trauma center are needed to reduce helicopter overutilization.

Air Ambulances↗
PubMed2005

Cardiac Arrest Resuscitation Evaluation in Los Angeles: CARE-LA.

STUDY OBJECTIVE: We determine survival for out-of-hospital cardiac arrests in Los Angeles using the Utstein method and compare these data with that reported for other urban and suburban areas. METHODS: This was a prospective observational cohort study of adult patients in Los Angeles presenting with nontraumatic, out-of-hospital cardiac arrest and with attempted out-of-hospital resuscitative efforts between July 1, 2000, and July 1, 2001. Entry criteria, time intervals, and nodal events conformed to Utstein template recommendations. The single target endpoint was neurologically intact survival at hospital discharge. RESULTS: Of 2,021 consecutive cardiac arrest patients on whom resuscitation was attempted, 1,700 (84%) met entry criteria as a primary cardiac event. Overall, neurologically intact survival was 1.4% (99% confidence interval [CI] 0.8% to 2.4%) Three patients were lost to follow-up. Survival from bystander-witnessed ventricular fibrillation was 6.1% (99% CI 3.3% to 11.0%). Absolute survival differences from witnessed ventricular fibrillation was higher but not statistically different than that from Chicago (-3%; 99% CI -8% to 2%) and New York City (-2%; 99% CI -6% to 3%). The rate of bystander cardiopulmonary resuscitation (CPR) for our population was 28%, for which the overall survival rate was 2.1%. The survival rate for patients with witnessed arrests and bystander CPR was 3.2%. Among patients with no bystander CPR, the survival rate was 1.0%. CONCLUSION: Survival from out-of-hospital cardiac arrest in Los Angeles was low but similar to that reported for New York and Chicago. This low survival rate may be due to population density, low bystander CPR rates, and traffic congestion delaying emergency response.

Adult↗
PubMed2005

Termination of resuscitative efforts for out-of-hospital cardiac arrests.

OBJECTIVE: To determine the rate of termination of resuscitative efforts for out-of-hospital cardiac arrest patients and whether variability exists among different base hospitals providing online medical control (OLMC). METHODS: This was an observational one-year study that included all adult patients in the city of Los Angeles with nontraumatic, out-of-hospital cardiac arrests with attempted resuscitative efforts by paramedics. OLMC was provided by 13 base hospitals. The main outcome measure was the incidence of termination of resuscitative efforts on scene as directed by OLMC. RESULTS: Of 1,700 patients, 151 (9%) had resuscitative efforts terminated on scene via direction by OLMC. Patients pronounced on scene were statistically more likely to be older, be found in an extended care facility, have an unwitnessed arrest, and present in asystole. Two base hospitals were more likely to terminate resuscitative efforts via OLMC than all others. Incidence at base hospital A was 37% (odds ratio, 18.6; 95% confidence interval = 11.7 to 30.0; p < 0.0001); incidence at base hospital B was 14% (odds ratio, 3.3; 95% confidence interval = 1.9 to 5.5; p < 0.0001), and incidence at all other base hospitals was 5%. Cardiac arrest patients handled by base hospital A were more likely to be found in ventricular fibrillation; those patients handled by base hospital B had shorter emergency medical services response times and were more likely to be found in an extended care facility. All other characteristics of cardiac arrest patients were not significantly different among the base hospitals. CONCLUSIONS: There is significant variability in Los Angeles, depending on the particular base hospital that provides OLMC, in pronouncement of death and termination of resuscitative efforts for medical cardiac arrest in the field. Given potential ethical, logistical, and economic concerns, efforts to assure consistency in the practice of discontinuing resuscitative efforts in the field is warranted.

Adult↗
PubMed2004

Prehospital neuroprotective therapy for acute stroke: results of the Field Administration of Stroke Therapy-Magnesium (FAST-MAG) pilot trial.

BACKGROUND AND PURPOSE: To demonstrate that paramedic initiation of intravenous magnesium sulfate (Mg) in the field in focal stroke patients is feasible, safe, and yields significant time-savings compared with in-hospital initiation of neuroprotective therapy. METHODS: We performed an open-label clinical trial. Inclusion criteria were: (1) likely stroke as identified by the Los Angeles Prehospital Stroke Screen; (2) age 45 to 95; and (3) treatment initiation within 12 hours of symptom onset. Paramedics initiated 4 g Mg loading dose in the field, followed by 16 g over 24 hours in hospital. RESULTS: Twenty patients were enrolled, with mean age 74 (range 44 to 92), and 50% were male. Final diagnosis was acute cerebrovascular disease in all (ischemic 80%, hemorrhagic 20%). Study agent infusion began a median of 100 minutes after symptom onset (range 24 to 703), and 70% received study agent within 2 hours of onset. The interval from paramedic arrival on scene to study agent start was: field-initiated, 26 minutes (range 15 to 64) versus in-hospital initiated (historic controls), 139 minutes (range 66 to 300; P<0.0001). Paramedics rated patient status on hospital arrival as improved 20%, worsened 5%, and unchanged 75%. Median NIHSS on hospital arrival was 11 in all patients and 16 in patients unchanged since field treatment start. Good functional outcome at 3 months (Rankin < or = 2) occurred in 60%. No serious adverse events were associated with field therapy initiation. CONCLUSIONS: Field initiation of Mg sulfate in acute stroke patients is feasible and safe. Prehospital trial conduct substantially reduces on-scene to needle time and permits hyperacute delivery of neuroprotective therapy.

Aged↗
PubMed2004

The effect of emergency department crowding on paramedic ambulance availability.

STUDY OBJECTIVE: We determine the effect of emergency department (ED) crowding on paramedic ambulance availability. METHODS: This was a prospective longitudinal study from April 2001 through March 2002 in Los Angeles, CA. All incidents in which a Los Angeles Fire Department ambulance was out of service for more than 15 minutes while waiting to transfer a patient because of the lack of open ED beds were captured and analyzed. Data included the total time each ambulance was out of service and the hospital where paramedics were waiting for an open gurney. Analysis was performed to determine weekly and seasonal variations and preponderance at various hospitals. RESULTS: There were a total of 21,240 incidents in which ambulances were out of service while waiting to transfer their patients to an open ED gurney, which accounted for 1 of every 8 transports. Of these, 8.4% were in excess of 1 hour. The median waiting time per incident was 27 minutes, with an interquartile range of 20 to 40. There was a statistically significant difference in the monthly number of out-of-service incidents during the study (P<.0001), with the highest levels during the winter (January through March). CONCLUSION: ED crowding has resulted in delays for paramedics waiting to transfer patients. This decrease in ambulance availability may have a significant effect on emergency medical services systems' abilities to provide timely response.

Allied Health Personnel↗
PubMed2002

Ability of paramedics to treat patients with congestive heart failure via standing field treatment protocols.

The objective of the study was to determine if paramedics can accurately select the appropriate standing field treatment protocol (SFTP) in lieu of on-line medical direction (OLMD) for patients with congestive heart failure. A prospective case series over 18 months determined the sensitivity and positive predictive value (PPV) of paramedics' treatment of CHF patients using SFTPs. All patients who were treated under the "rales" protocol and transported to our base hospital were evaluated for appropriateness of field treatment with correlation to discharge diagnosis. During this same time interval all patients ultimately diagnosed with CHF and treated by paramedics under any SFTP were studied. A total of 104 patients met the inclusion criteria with 102 available for analysis. Of the 58 patients treated under the rales protocol 50 (86%) had an ED diagnosis of CHF and 8 (13%) had a primary respiratory diagnosis. The remaining 44 (43%) of the 102 patients studied were treated under an SFTP other than rales but had a discharge diagnosis of CHF. Overall sensitivity for paramedics' correctly identifying CHF was 53%. Their PPV was 86%. In this study paramedics correctly identified only about half of the dyspneic patients who proved to have CHF, but their assessment of CHF did have a higher positive predictive value when this diagnosis was made. Further training and quality improvement efforts need to be directed towards improving paramedic performance with this challenging group of patients, with consideration given to requiring OLMD for patients presenting with rales.

Adult↗
PubMed2002

Helicopter transport of pediatric trauma patients in an urban emergency medical services system: a critical analysis.

BACKGROUND: Helicopter transport of pediatric trauma patients in an urban Emergency Medical Services system remains controversial. METHODS: A retrospective review of pediatric patients transported by helicopter to a pediatric trauma center in Los Angeles, California, was conducted over a 3-year period. Pediatric patients (age < 15 years) are transported by helicopter if ground transport to a pediatric trauma center would exceed 20 minutes. Emergency Medical Services reports and hospital records were reviewed for key prehospital and outcome indicators. RESULTS: One hundred eighty-nine patients met the study inclusion criteria. The median age was 5 years (range, 0-14 years). The most common mechanisms of injury were falls and automobile versus pedestrian crashes. Eighty-two percent of patients had a Revised Trauma Score > 7. Of the 175 (93%) patients whose hospital records were available, 24 (14%) were intubated in the emergency department, 32 (18%) were admitted to the intensive care unit, and 7 (4%) were taken directly to the operating room. Injury Severity Scores (ISSs) were as follows: ISS 0 to 15, 146 (83%); ISS 16 to 30, 26 (15%); and ISS > 30, 3 (2%). Fifty-seven (33%) patients were discharged home from the emergency department. CONCLUSION: The majority of pediatric trauma patients transported by helicopter in our study sustained minor injuries. A revised policy to better identify pediatric patients who might benefit from helicopter transport appears to be warranted.

Adolescent↗
PubMedDate not supplied

Primum non nocere--first do no harm: an imperative for emergency medical services.

Unlike the response to landmark studies in other disciplines of medicine, the few existing controlled, randomized EMS studies have not led to any calls for "moratoriums" on the practices in question. Why haven't they? It is all too easy to continue to dismiss the negative results of studies from a system other than our own. The paramedics in the system studied were not as well trained, were not as closely supervised, or did not have adequate medical oversight; the study was flawed, etc. Any or all of these variables may be true. A particular system may be safely performing one of the practices in question. However, the published results of any study that finds a high-risk practice to be more harmful than beneficial should immediately mandate the close examination of the practice in each and every system. To do otherwise is in direct conflict with the mission of EMS, and minimizes the value of the lives of the people in the communities who depend on us. First do no harm... is anyone listening?

Accidents, Traffic↗
PubMedDate not supplied

Focus on smoke inhalation--the most common cause of acute cyanide poisoning.

The contribution of smoke inhalation to cyanide-attributed morbidity and mortality arguably surpasses all other sources of acute cyanide poisoning. Research establishes that cyanide exposure is: (1) to be expected in those exposed to smoke in closed-space fires; (2) cyanide poisoning is an important cause of incapacitation and death in smoke-inhalation victims; and (3) that cyanide can act independently of, and perhaps synergistically with, carbon monoxide to cause morbidity and mortality. Effective prehospital management of smoke inhalation-associated cyanide poisoning is inhibited by: (1) a lack of awareness of fire smoke as an important cause of cyanide toxicity; (2) the absence of a rapidly returnable diagnostic test to facilitate its recognition; and (3) in the United States, the current unavailability of a cyanide antidote that can be used empirically with confidence outside of hospitals. Addressing the challenges of the prehospital management of smoke inhalation-associated cyanide poisoning entails: (1) enhancing the awareness of the problem among prehospital responders; (2) improving the ability to recognize cyanide poisoning on the basis of signs and symptoms; and (3) expanding the treatment options that are useful in the prehospital setting.

Acute Disease↗