IntroductionPre-hospital induction of therapeutic mild hypothermia (TH) may reduce post-cardiac arrest brain injury in patients resuscitated from out-of-hospital cardiac arrest. Most often, it is induced by a rapid intravenous administration of as much as 30 ml/kg of cold crystalloids. We decided to assess the pre-hospital cooling effectivity of this approach by using a target dose of 15-20 ml/kg of 4°C cold normal saline in the setting of the physician-staffed Emergency Medical Service. The safety and impact on the clinical outcome have also been analyzed.MethodsWe performed a prospective observational study with a retrospective control group. A total of 40 patients were cooled by an intravenous administration of 15-20 ml/kg of 4°C cold normal saline during transport to the hospital (TH group). The pre-hospital decrease of tympanic temperature (TT) was analyzed as the primary endpoint. Patients in the control group did not undergo any pre-hospital cooling.ResultsIn the TH group, administration of 12.6 ± 6.4 ml/kg of 4°C cold normal saline was followed by a pre-hospital decrease of TT of 1.4 ± 0.8°C in 42.8 ± 19.6 min (p < 0.001). The most effective cooling was associated with a transport time duration of 38-60 min and with an infusion of 17 ml/kg of cold saline. In the TH group, a trend toward a reduced need for catecholamines during transport was detected (35.0 vs. 52.5%, p = 0.115). There were no differences in demographic variables, comorbidities, parameters of the cardiopulmonary resuscitation and in other post-resuscitation characteristics. The coupling of pre-hospital cooling with subsequent in-hospital TH predicted a favorable neurological outcome at hospital discharge (OR 4.1, CI95% 1.1-18.2, p = 0.046).ConclusionsPre-hospital induction of TH by the rapid intravenous administration of cold normal saline has been shown to be efficient even with a lower dose of coolant than reported in previous studies. This dose can be associated with a favorable impact on circulatory stability early after the return of spontaneous circulation and, when coupled with in-hospital continuation of cooling, can potentially improve the prognosis of patients.Trial RegistrationClinicalTrials (NCT): NCT00915421

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Introduction: Prehospital and emergency medical services (EMS) providers are usually the first to respond to an individual's urgent health needs, sometimes in emotionally charged circumstances. Because violence toward EMS providers in the Czech Republic is often overlooked and under-reported, we do not have a complete understanding of the extent of such violence, nor do we have recommendations from EMS professional organizations on how to resolve this problem in prehospital emergency medicine. Methods:We conducted this study to explore the process of violence against EMS providers, using the Strauss/Corbin systematic approach of grounded theory to create a paradigm model. The participants in this research included personnel who had at least two years experience in the EMS systems of the city of Prague and the Central Bohemian Region, and who had been victims of violence. Our sample included 10 registered paramedics and 10 emergency medical technicians ages 23-33 (mean ± standard deviation: 27.7). The impact of communication during EMS delivery, in the context of violence from patients or their relatives, emerged as the core category and the main focus of our study. The five main groups of the paradigm model of violence against EMS personnel included causal, contextual and intervening conditions, strategies, and consequences.Results: Of the 20 study participants, 18 reported experiencing an attack during the night shift. Ten participants experienced violence on the street, and 10 inside an ambulance. The perpetrators in all 18 cases were men. The behavior of EMS personnel plays a crucial role in how violent confrontations play out: nonprofessional behavior with drunken or addict patients increases the possibility of violence in 70% of cases. Conclusion:We found that paramedics and EMTs were exposed to verbal abuse and physical violence. However, in 10 of the violent encounters reported by our 20 participants, the attack was perpetrated by otherwise-ordinary people (ie, individuals with strong family support and good jobs) who found themselves in a very stressful situation. Thanks to grounded theory we learned that for all 20 participants there was a potential opportunity to prevent the conflict.

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Background. The presence of gasping in out-of-hospital cardiac arrest (OHCA) patients predicts short-term prognosis. We performed a retrospective study to evaluate whether the presence of gasping at the time of Emergency Medical Service (EMS) arrival in the case OHCA patients of presumed cardian origin has any impact on six-month survival and/ or sustained return of spontaneous circulation (ROSC). Methods. We collected and analyzed Utstein Style data for all patients resuscitated for OHCA of presumed cardiac origin by the EMS of the Central Bohemian Region from Results. During the data collection period, 565 cases of OHCA of presumed cardiac origin were reported. Gasping at the time of EMS arrival was identified in 23.9%. The presence of gasping was associated with a significantly increased frequency of sustained ROSC (48.1 versus 20.7%, P<0.001) and six-month survival (40.7 versus 16.7%, P<0.001) than in non-breathing patients. Presence of gasping upon EMS arrival has been found to be an independent positive predictor of sustained ROSC (OR 2.51, CI 95% 1. 59-3.98, P<0.001). The occurrence of gasping at the time of EMS arrival at the scene was significantly related to response time from EMS activation to arrival. Conclusion. The presence of gasping upon arrival of the EMS for the patient with OHCA of presumed cardiac origin predicts both improves short-term and long-term prognoses.

Rewarming of cold NS during application in prehospital conditions is a typical occurrence. Considering that the use of 250 ml bags means the infusion must be exchanged too frequently during cooling, the use of 500 or 1000 ml NS bags applied at an infusion rate of ≥4000 ml/h and termination of the infusion when 80% of the infusion volume has been administered is regarded as optimal.

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