Henry E. Wang, Mengda Yu, Ching Min Chu, Travis P. Sharkey-Toppen, J. Madison Hyer, Michelle Nassal, Alix Delamare, Jonathan Powell, Lai Wei, Robert Lowe, Kim Moeller, Alexander Keister, Ashish Panchal
Clin Exp Emerg Med 2025;12(4):350-357. Published online April 30, 2025
Objective Oral anticoagulant (OAC) use increases the risk of death in conditions like hemorrhagic stroke, trauma, and traumatic brain injury. Early identification of OAC use is critical for timely interventions to mitigate hemorrhage risk and improve survival. We aimed to identify emergency medical services (EMS) care characteristics associated with patients using an OAC.
Methods We analyzed prehospital data (2018–2020) from the ESO Data Collaborative, focusing on adult (≥18 years) 911 EMS calls. The administered OACs were warfarin, dabigatran, rivaroxaban, and apixaban. We compared EMS call characteristics, patient demographics, response times, and interventions between OAC and non-OAC users. We used univariate logistic regression to identify independent predictors of OAC use.
Results Of 16,244,550 adult 911 EMS events, 906,575 involved OAC users (56 of 1,000 calls). Those using OAC were older (73.6 years vs. 56.9 years) and more often from nursing homes or long-term care facilities (17.0% vs. 9.2%) but less likely to have trauma (14.7% vs. 18.1%) or cardiac arrest (1.2% vs. 1.4%). The most common EMS primary clinical impressions for OAC users were chest pain (7.4%), altered mental status (7.3%), injury (6.5%), abdominal pain (4.3%), and brain injury (2.8%).
Conclusion OAC users accounted for 1 in 18 adult EMS encounters. Specific patient and call characteristics were associated with OAC use. These findings should be incorporated into EMS training to facilitate recognition and appropriate management of OAC-related emergencies.
Prompt activation of emergency medical services (EMS) constitutes the fundamental component of bystander response to time-dependent health crises. A clear understanding of the public ability to access EMS can help to guide interventions aimed at enhancing community preparedness for emergencies. This review was conducted to summarize studies that examined public knowledge of emergency phone numbers. This scoping review encompassed articles published since 2004 that reported the proportion of subjects who knew emergency phone numbers. Data sources included PubMed, Google Scholar, and references of included articles. Relevant data from eligible publications were extracted manually to an author-developed data-charting sheet and analyzed descriptively. Forty-eight articles were analyzed. Reported studies, mostly cross-sectional surveys, were conducted in 26 countries, including 16 high-income, 9 middle-income, and 1 low-income country. The percentage of subjects who knew emergency numbers varied from 0% to 97.8% (median, 64.3%; interquartile range [IQR], 32.8%–80.0%). For high-income countries, the median was significantly higher than for low- and middle-income nations (69.6% [IQR, 54.1%–84.2%] vs. 34.6% [IQR, 19.4%–61.5%], P=0.003). The studies were generally inconsistent regarding the association of subjects’ sociodemographic factors with knowledge of emergency numbers, suggesting the existence of geography-specific patterns. Available studies observed low community knowledge of emergency numbers, especially in low- and middle-income countries, and suggest that the problem has a global scale. Further research efforts are required to determine the best strategies for enhancing the public ability to access EMS.
Objective The Korean National Fire Agency conducted a pilot project examining Advanced Life Support (ALS) protocols, including epinephrine administration, to improve survival among patients suffering out-of-hospital cardiac arrest (OHCA). In this study, we aimed to evaluate the effects of the Korean National Fire Agency ALS protocol on prehospital return of spontaneous circulation (ROSC) in patients with OHCA.
Methods This study included patients with adult-presumed cardiac arrest between January and December 2020. The main factor of interest was ambulance type according to ALS protocol, which was divided into dedicated ALS ambulance (DA), smartphone-based ALS ambulance (SALS), and non-DA, and the main analysis factor was prehospital ROSC. Multivariate logistic regression analysis was performed.
Results During the study period, a total of 18,031 adult patients with OHCA was treated by the emergency medical services, including 7,520 DAs (41.71%), 2,622 SALSs (14.54%), and 7,889 non-DAs (43.75%). The prehospital ROSC ratio was 13.19% for DA, 11.17% for SALS, and 7.91% for non-DA (P<0.01). Compared with that of the DA group, the odds ratios (95% confidence interval) for prehospital ROSC ratio were 0.97 (0.82–1.15) in the SALS group and 0.57 (0.50–0.65) in the non-DA group. The prehospital ROSC ratio of the DA group was higher than those of the non-DA group and the SALS group.
Conclusion ALS protocol intervention was associated with prehospital ROSC rates. Therefore, continuous efforts to promote systemic implementation of the ALS protocol to improve OHCA outcomes are necessary.
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In a prehospital setting, the narrow therapeutic window of epinephrine necessitates its cautious administration to avoid anaphylaxis. In this case, a 46-year-old man presented severe anaphylactic symptoms. Following the standard protocol, the emergency medical technician (EMT) administered intramuscular epinephrine; however, symptoms persisted. Under the oversight of the emergency medical services (EMS) medical director, an additional intravenous bolus of epinephrine was administered, unfortunately leading to atrial fibrillation. This case underscores the potential risks of intravenous epinephrine, which is not typically recommended for anaphylaxis without continuous monitoring. Since 2019, Korea has initiated a pilot program to expand the EMT scope of practice, which gives them the authority to administer epinephrine for anaphylaxis. The ultimate decision regarding epinephrine use for anaphylaxis, emphasizing patient safety, rests with the EMS medical director. Proper training for EMTs, coupled with the EMS medical director’s comprehensive knowledge and meticulous protocol adherence, can ensure patient safety and optimal outcomes.
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Objective Myocardial rupture is a fatal complication of acute myocardial infarction (AMI). Early diagnosis of myocardial rupture is feasible when emergency physicians (EPs) perform emergency transthoracic echocardiography (TTE). The purpose of this study was to report the echocardiographic features of myocardial rupture on emergency TTE performed by EPs in the emergency department (ED).
Methods This was a retrospective and observational study involving consecutive adult patients presenting with AMI who underwent TTE performed by EPs in the ED of a single academic medical center from March 2008 to December 2019.
Results Fifteen patients with myocardial rupture, including eight (53.3%) with free wall rupture (FWR), five (33.3%) with ventricular septal rupture (VSR), and two (13.3%) with FWR and VSR, were identified. Fourteen of the 15 patients (93.3%) were diagnosed on TTE performed by EPs. Diagnostic echocardiographic features were found in 100% of the patients with myocardial rupture, including pericardial effusion for FWR and a visible shunt on the interventricular septum for VSR. Additional echocardiographic features indicating myocardial rupture were thinning or aneurysmal dilatation in 10 patients (66.7%), undermined myocardium in six patients (40.0%), abnormal regional motions in six patients (40.0%), and pericardial hematoma in six patients (40.0%).
Conclusion Early diagnosis of myocardial rupture after AMI is possible using echocardiographic features on emergency TTE performed by EPs.
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Objective The number and distribution of isolation rooms in Korea differ by region. The distribution of isolation beds in emergency departments may have affected ambulance travel time and burden on emergency medical service (EMS) during the COVID-19 pandemic.
Methods This retrospective observational study analyzed EMS records in four regions of the Gyeonggi Province, Korea, from January 01, 2019 to December 31, 2020. The main exposure was the number of emergency department isolation rooms in each region. The primary outcome was call-to-return time for the EMS. The interaction effect of the number of regional isolation rooms on the call-to-return time during the COVID-19 pandemic was analyzed using a generalized linear model (GLM) and logistic regression.
Results A total of 781,246 cases was included in the analyses. During the COVID-19 pandemic, the call-to-scene time (before 8 minutes vs. after 9 minutes, P<0.05) and call-to-return time (before 46 minutes vs. after 52 minutes, P<0.05) for emergency patients increased significantly compared to before the pandemic. As the number of regional isolation rooms increased, the effect of COVID-19 on the call-to-return time decreased significantly in the multivariable GLM with an interaction term (with 10.14 isolation rooms per million population: adjusted exponential β coefficient [exp(β)], 1.33; with 12.24 isolation rooms per million population: adjusted exp(β), 1.18). As the number of regional isolation rooms increased, the effect of COVID-19 on the call-to-scene time decreased significantly in the multivariable GLM with an interaction term (with 10.14 isolation rooms per million population: adjusted exp(β), 1.20; with 12.24 isolation rooms per million population: adjusted exp(β), 1.09).
Conclusion During the pandemic, the increases in call-to-return time and call-to-scene time were smaller in regions with more isolation rooms per population.
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Sol Han, Sung Wook Song, Hansol Hong, Woo Jeong Kim, Young Joon Kang, Chang Bae Park, Jeong Ho Kang, Ji Hwan Bu, Sung Kgun Lee, Seo Young Ko, Soo Hoon Lee, Chul-Hoo Kang
Clin Exp Emerg Med 2023;10(2):213-223. Published online February 14, 2023
Objective This study investigated the hospital diagnoses and characteristics of uncooperative prehospital patients suspected of acute stroke who could not undergo a prehospital stroke screening test (PHSST).
Methods This retrospective observational study was conducted at a single academic hospital with a regional stroke center. We analyzed three scenario-based prehospital stroke screening performances using the final hospital diagnoses: (1) a conservative approach only in patients who underwent the PHSST, (2) a real-world approach that considered all uncooperative patients as screening positive, and (3) a contrapositive approach that all uncooperative patients were considered as negative.
Results Of the 2,836 emergency medical services (EMS)-transported adult patients who met the prehospital criteria for suspicion of acute stroke, 486 (17.1%) were uncooperative, and 570 (20.1%) had a confirmed final diagnosis of acute stroke. The diagnosis in the uncooperative group did not differ from that in the cooperative group (22.0% vs. 19.7%, P=0.246). The diagnostic performances of the PHSST in the conservative approach were as follows: 79.5% sensitivity (95% confidence interval [CI], 75.5%–83.1%), 90.2% specificity (95% CI, 88.8%–91.6%), and 0.849 area under the receiver operating characteristic curve (AUC; 95% CI, 0.829–0.868). The sensitivity and specificity were 83.3% (95% CI, 80.0%–86.3%) and 75.2% (95% CI, 73.3%–76.9%), respectively, in the real-world approach and 64.6% (95% CI, 60.5%–68.5%) and 91.9% (95% CI, 90.7%–93.0%), respectively, in the contrapositive approach. No significant difference was evident in the AUC between the real-world approach and the contrapositive approach (0.792 [95% CI, 0.775–0.810] vs. 0.782 [95% CI, 0.762–0.803], P>0.05).
Conclusion We found overestimation (false positive) and underestimation (false negative) in the uncooperative group depending on the scenario-based EMS stroke screening policy for uncooperative prehospital patients suspected of acute stroke.
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Objective According to the 2019 European Society of Cardiology (ESC) guidelines on pulmonary embolism (PE), prognosis is calculated using the Pulmonary Embolism Severity Index (PESI), a complex score with debated validity, or simplified PESI (sPESI). We have developed and validated a new risk score for in-hospital mortality (IHM) of patients with PE in the emergency department.
Methods This retrospective, dual-center cohort study was conducted in the emergency departments of two third-level university hospitals. Patients aged >18 years with a contrast-enhanced computed tomography-confirmed PE were included. Clinical variables and laboratory tests were evaluated blindly to IHM. Multivariable logistic regression was performed to identify the new score’s predictors, and the new score was compared with the PESI, sPESI, and shock index.
Results A total of 1,358 patients were included in this study: 586 in the derivation cohort and 772 in the validation cohort, with a global 10.6% of IHM. The PATHOS scores were developed using independent variables to predict mortality: platelet count, age, troponin, heart rate, oxygenation, and systolic blood pressure. The PATHOS score showed good calibration and high discrimination, with an area under the receiver operating characteristics curve of 0.83 (95% confidence interval [CI], 0.77–0.89) in the derivation population and 0.74 (95% CI, 0.68–0.80) in the validation cohort, which is significantly higher than the PESI, sPESI, and shock index in both cohorts (P<0.01 for all comparisons).
Conclusion PATHOS is a simple and effective prognostic score for predicting IHM in patients with PE in an emergency setting.
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Objective This study aimed to evaluate the association between the number and level of emergency medical technicians (EMTs) in the first-contact emergency medical services (EMS) unit and the clinical outcomes of out-of-hospital cardiac arrest (OHCA) with a dual dispatch response.
Methods Adult nontraumatic EMS-treated OHCAs between 2015 and 2018 in a nationwide database, were enrolled. The main exposure was the number and certification level of first-contact EMS crew: three versus two members, proportion of EMT intermediate level (EMT-I) over 50% versus under or equal to 50%. Good neurologic recovery was selected as the primary outcome. Multilevel multivariable logistic regression analysis was conducted to calculate adjusted odds ratios and confidence intervals.
Results A total of 26,867 patients were enrolled and analyzed. Good neurologic recovery was different across the study groups: 5.4% in the two-member crews, 7.2% in the three-member crews, 5.9% in the low EMT-I proportion crews, and 6.8% in the high EMT-I proportion crews. In the main analysis, statistically significant differences for favorable outcomes were found between the three-member and two-member crews, and the high EMT-I proportion and low EMT-I proportion crews; for good neurologic recovery, adjusted odds ratios (95% confidence interval) were 1.23 (1.06–1.43) for three-member crews, and 1.28 (1.17–1.40) for a high EMT-I proportion.
Conclusion The higher number and level of first-contact EMS crew was associated with better neurologic recovery in adult nontraumatic OHCA with a dual-dispatched EMS response.
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Objective This study aimed to assess and compare emergency department (ED) workloads by using relative value units (RVUs) before and during the COVID-19 pandemic.
Methods This retrospective observational study investigated the RVUs of a single ED from 2019 to 2021. We calculated the mean number of patients per day (PPD) for each year and selected the days when the number of patients was equal to the yearly mean PPD for each of the three years. We calculated the total RVUs per day and RVUs per patient and compared them.
Results We analyzed the RVUs of 12 days in 2019 (mean PPD, 88), 10 days in 2020 (mean PPD, 75), and 14 days in 2021 (mean PPD, 83). The mean of the total RVUs per day were as follows: 533,057.5±66,239.1 in 2019, 505,994.6±48,935.4 in 2020, and 634,219.6±64,024.2 in 2021 (P<0.001). The RVUs per patient in the three year-groups were significantly different (6,057.5±
752.7 in 2019, 6,746.6±652.5 in 2020, and 7,641.2±771.4 in 2021; P<0.001). Post hoc analyses indicated that the total RVUs per day and the RVUs per patient in 2021 were significantly higher than in 2019 or 2020, although the mean PPD in 2019 was the highest.
Conclusion Since the onset of the COVID-19 pandemic, the mean RVUs per patient have increased, suggesting that the workload per patient may also have increased in the regional emergency medical center.
Objective This study investigated the characteristics and survival rates of patients with unintentional severe trauma who visited a regional trauma center (TC) or a non-TC.
Methods This retrospective, national, population-based, observational, case-control study included patients with abnormal Revised Trauma Score from January 2018 to December 2018. We divided hospitals into two types, TC and non-TC, and compared several variables, including in-hospital mortality. Propensity score matching was used to reduce the effect of confounding variables that influence survival outcome variables.
Results Of the 25,743 patients, 5,796 visited a TC and 19,947 visited a non-TC. Compared to patients treated at non-TCs, patients treated at TCs were more likely to have a higher Injury Severity Score (TC, 11.5; non-TC, 7.4; P<0.001), higher rate of surgery or transcatheter arterial embolization (TC, 39.2%; non-TC, 17.6%; P<0.001), and higher admission rate (TC, 64.7%; non-TC, 36.9%; P<0.001) through the emergency department. After propensity score matching, 2,800 patients from both groups were analyzed. Patients in the TC had a higher survival rate than patients that were not treated in the TC (TC, 83.0%; non-TC, 78.6%; P=0.003).
Conclusion This study using Korean emergency medical services data showed that initial transport to trauma centers was associated with mortality reduction. Further research is required because of limitations with use of single-year data and retrospective design.
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Objective We hypothesized that a multi-tier response (MTR) will provide high-quality cardiopulmonary resuscitation including airway management. However, the type of tier response system and airway management will have different interactive effects resulting in varying outcomes following out-of-hospital cardiac arrest (OHCA). This study aimed to determine whether the advanced airway management method has an effect on OHCA outcomes and to compare the size of the effect across MTR types.
Methods This is a retrospective population-based observational study using the Korea OHCA Registry. Airway management methods were categorized into endotracheal intubation (ETI) and supraglottic airway (SGA) groups. The tier system was categorized into single-tier response (STR) or two types of MTR: ambulance-ambulance MTR or fire engine-ambulance MTR.
Results In total, 45,264 patients were analyzed among the 89,087 emergency medical service assessed OHCAs. The SGA group was significantly associated with a lower prehospital return of spontaneous circulation (ROSC) rate compared to the ETI group (adjusted odds ratio [aOR], 0.79; 95% confidence interval [CI], 0.72–0.88). Both MTR with an ambulance or fire engine were significantly associated with higher prehospital ROSC rates compared to STR (STR vs. MTR with an ambulance: aOR, 1.33; 95% CI, 1.21–1.47; STR vs. MTR with a fire engine: aOR, 1.43; 95% CI, 1.20–1.71). Prehospital SGA was significantly associated with poor neurological outcomes in MTR with fire engine (aOR, 0.71; 95% CI, 0.53–0.96).
Conclusion In this nationwide observational study, we observed that MTR was associated with higher prehospital ROSC than STR. Moreover, SGA is associated with a lower prehospital ROSC rate regardless of tier response type compared to ETI.
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Objective This study aimed to evaluate the association between prehospital recognition of acute myocardial infarction (AMI) and length of stay (LOS) in the emergency department (ED) of emergency medical service (EMS)-transported AMI patients.
Methods A multicenter retrospective observational study was conducted using prehospital and hospital data from three tertiary emergency departments. Patients diagnosed with AMI between January 2015 and December 2018 were enrolled. Study groups were categorized according to prehospital recognition and prehospital 12-lead electrocardiography (ECG) into three groups based on an EMS cardiovascular registry: group A, no prehospital recognition (reference group); group B, prehospital recognition without 12-lead ECG; and group C, prehospital recognition with 12-lead ECG. The primary outcome was an ED LOS of less than 4 hours.
Results Among 1,237 study participants, 722 (58.4%) were in group A, 325 (26.3%) were in group B, and 190 (15.4%) were in group C. Multivariable logistic regression showed that groups B and C had a higher likelihood of a short ED LOS (adjusted odds ratio [95% confidence interval]: group B, 1.64 [1.21–2.22] and group C, 1.88 [1.30–2.71]) than group A. There was no significant difference in ED LOS according to whether prehospital 12-lead ECG was conducted.
Conclusion Prehospital recognition of AMI by EMS personnel, with or without 12-lead ECG, was associated with a short ED LOS.
Chanhong Min, Dong Eun Lee, Hyun Wook Ryoo, Haewon Jung, Jae Wan Cho, Yun Jeong Kim, Jae Yun Ahn, Jungbae Park, You Ho Mun, Tae Chang Jang, Sang-chan Jin
Clin Exp Emerg Med 2022;9(3):207-215. Published online August 31, 2022
Objective High-quality cardiopulmonary resuscitation with chest compression is important for good neurologic outcomes during out-of-hospital cardiac arrest (OHCA). Several types of mechanical chest compression devices have recently been implemented in Korean emergency medical services. This study aimed to identify the effect of prehospital mechanical chest compression device use on the outcomes of OHCA patients.
Methods We retrospectively analyzed data drawn from the regional cardiac arrest registry in Daegu, Korea. This registry prospectively collected data from January 2017 to December 2020. Patients aged 18 years or older who experienced cardiac arrest presumed to have a medical etiology were included. The exposure variable was the use of a prehospital mechanical device during transportation by emergency medical technicians. The outcomes measured were neurologic outcomes and survival to discharge. Logistic regression analysis was used.
Results Among 3,230 OHCA patients, 1,111 (34.4%) and 2,119 (65.6%) were managed with manual chest compression and with a mechanical chest compression device, respectively. The mechanical chest compression group showed poorer neurologic outcomes than the manual chest compression group (adjusted odds ratio, 0.12; 95% confidence interval, 0.04–0.33) and decreased survival to discharge (adjusted odds ratio, 0.39; 95% confidence interval, 0.19–0.82) after adjustment for confounding variables.
Conclusion Prehospital mechanical chest compression device use in OHCA was associated with poorer neurologic outcomes and survival to discharge compared to manual chest compression.
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Objective This study analyzed the association of transport time interval (TTI) with survival rate and neurologic outcome in out-of-hospital cardiac arrest (OHCA) patients without return of spontaneous circulation (ROSC) and the interaction effect of TTI according to prehospital airway management.
Methods A retrospective observational study based on the nationwide OHCA database from January 2013 to December 2017 was designed. Emergency medical service (EMS)-treated OHCA patients aged ≥18 years were included. TTI was categorized into four groups of quartiles (≤4, 5–7, 8–11, ≥12 minutes). The primary outcome was favorable neurologic outcome at discharge. The secondary outcome was survival to discharge from the hospital. Multivariable logistic regression was used to analyze outcomes according to TTI. A different effect of TTI according to the administration of prehospital EMS advanced airway was evaluated.
Results In total, 83,470 patients were analyzed. Good neurologic recovery decreased as TTI increased (1.0% for TTI ≤4 minutes, 0.9% for TTI 5–7 minutes, 0.6% for TTI 8–11 minutes, and 0.5% for TTI ≥12 minutes; P for trend <0.05). The adjusted odds ratio of prolonged TTI (≥12 minutes) was 0.73 (95% confidence interval, 0.57–0.93; P<0.01) for good neurologic recovery. However, the negative effect of prolonged TTI on neurological outcome was insignificant when advanced airway or entotracheal intubation were performed by EMS providers (adjusted odds ratio, 1.17; 95% confidence interval, 0.42–3.29; P=0.76).
Conclusion EMS TTI was negatively associated with the neurologic outcome of OHCA without ROSC on scene. When advanced airway was performed on scene, TTI was insignificantly associated with the outcome.
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